LeMone and Burke_s Medical-Surgical Nursing Clinical Reasoning in Patient Care, 7th Edition Gerene B

Test Bank for LeMone & Burke’s Medical-Surgical Nursing: Clinical Reasoning in Patient Care

Seventh Edition

Gerene Bauldoff Paula Gubrud Margaret-Ann Carno

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 1 Medical-Surgical Nursing in the 21st Century 1) A patient is instructed on the role of diet, exercise, and medication to control type 2 diabetes mellitus. Which core competency for healthcare professionals is the nurse implementing? 1. Quality improvement 2. Evidence-based practice 3. Patient-centered care 4. Teamwork and collaboration Answer: 3 Explanation: 1. Identifying safety hazards and measuring quality is an example of the core competency quality improvement. 2. Using best research when providing patient care is an example of the core competency evidence-based practice. 3. Patient teaching is an example of the competency patient-centered care. 4. The core competency teamwork and collaboration involves collaboration between disciplines to provide continuous and reliable care. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 1.1 Describe the core competencies for healthcare professionals: Patientcentered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 1. Demonstrate use of the core competencies for healthcare professionals in nursing practice.

1 ..

2) The nurse is planning to utilize the core competency use informatics when providing patient care. Which action should the nurse perform when using this core competency? 1. Change the sharps container in a patient's room. 2. Document the effectiveness of pain medication for a patient. 3. Discuss the effectiveness of bedside physical therapy with the therapist. 4. Search through a database of articles to find current research on wound care. Answer: 4 Explanation: 1. Changing the sharps container is an example of quality improvement. 2. Documenting the effectiveness of pain medication for a patient is an example of patientcentered care. 3. Discussing the effectiveness of bedside physical therapy with the therapist is an example of teamwork and collaboration. 4. Searching through a database of articles to find current research on wound care is an example of use informatics. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI.B.2. Apply technology and information management tools to support safe processes of care | AACN Essentials Competencies: IV.1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice | NLN Competencies: Knowledge and Science: Practice-Know-How: Retrieve research findings and other sources of information | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.1 Describe the core competencies for healthcare professionals: Patientcentered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 1. Demonstrate use of the core competencies for healthcare professionals in nursing practice.

2 ..

3) The nurse plans to implement evidence-based practice when providing patient care. Which activity should the nurse perform? Select all that apply. 1. Participate in education and research activities when possible. 2. Integrate research findings with clinical care to maximize patient outcomes. 3. Serve on the committee to create critical pathways for patient care. 4. Reinforce hand hygiene techniques with unlicensed assistive personnel. 5. Contact Environmental Services to report a malfunctioning infusion pump. Answer: 1, 2 Explanation: 1. Participating in education and research activities when possible is an example of implementing evidence-based practice in the provision of patient care. 2. Integrating research findings with clinical care to maximize patient outcomes is an example of implementing evidence-based practice in the provision of patient care. 3. Serving on the committee to create critical pathways for patient care is an example of teamwork and collaboration. 4. Reinforcing hand hygiene techniques with unlicensed assistive personnel is an example of quality improvement. 5. Contacting Environmental Services to report a malfunctioning infusion pump is an example of quality improvement. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III.B.6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice | AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice | NLN Competencies: Knowledge and Science; Knowledge: What is evidence-based practice (EBP)? Informatics? | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.1 Describe the core competencies for healthcare professionals: Patientcentered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 1. Demonstrate use of the core competencies for healthcare professionals in nursing practice.

3 ..

4) The nurse is planning to meet with several community members during a health fair. Which nursing activity exemplifies the core competency patient-centered care? 1. Provide smoking cessation classes and literature. 2. Increase the hours for the healthcare providers to see patients. 3. Attend a continuing education program on clean water initiatives. 4. Evaluate the effectiveness of weight reduction strategies. Answer: 1 Explanation: 1. Providing smoking cessation classes and literature is an example of an activity to provide patient-centered care. 2. Increasing the hours for the healthcare providers to see patients is an activity to support the competency teamwork and collaboration. 3. Attending a continuing education program on clean water initiatives is an activity to support the competency evidence-based practice. 4. Evaluating the effectiveness of weight reduction strategies is an activity to support the competency quality improvement. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX. 7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 1.1 Describe the core competencies for healthcare professionals: Patientcentered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 1. Demonstrate use of the core competencies for healthcare professionals in nursing practice.

4 ..

5) The nurse is instructing a patient on weight reduction and smoking cessation. Which code of nursing practice is the nurse implementing? 1. International Council of Nurses Code of Ethics for Nurses 2. American Nurses Association Standards of Professional Practice 3. American Nurses Association Code of Ethics for Nurses 4. State Board of Nursing Code Answer: 1 Explanation: 1. The International Council of Nurses (ICN) Code of Ethics for Nurses specifies what nurses are accountable for in terms of people, practice, society, coworkers, and the profession. The philosophical basis for this code is that nurses are responsible for promoting health, preventing illness, and alleviating suffering. Instructing a patient on weight reduction and smoking cessation exemplifies the ICN Code of Ethics for Nurses. 2. The American Nurses Association Standards of Professional Practice are standards, not a code, and focus on specific behaviors to address education, ethics, evidence-based practice and research, quality practice, communication, leadership, collaboration, professional resource utilization, and environmental health. 3. The American Nurses Association Code of Ethics for Nurses has nine statements that address the nurse's professional relationships, commitment to patients, patient rights, nursing practice, competency, conditions of employment, and contributions to the science of nursing, collaboration, and nursing values. 4. The state boards of nursing do not publish codes for nursing. Page Ref: 12-13 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.4. Use behavioral change techniques to promote health and manage illness | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

5 ..

6) The nurse is providing patient care within the American Nurses Association Standards of Professional Performance. Which activity is the nurse implementing? 1. Integrating research findings into practice 2. Implementing a patient's plan of care 3. Evaluating patient progress toward identified outcomes 4. Analyzing assessment data to determine issues Answer: 1 Explanation: 1. The nurse who is practicing within the American Nurses Association Standards of Professional Performance would integrate research findings into practice. The standards focus on ethics, education, evidence-based practice and research, quality nursing practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. 2. Implementing a patient's plan of care is an example of adhering to the American Nurses Association Standards of Practice. 3. Evaluating patient progress toward identified outcomes is an example of adhering to the American Nurses Association Standards of Practice. 4. Analyzing assessment data to determine issues is an example of adhering to the American Nurses Association Standards of Practice. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III.B.6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice | AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice | NLN Competencies: Knowledge and Science; Knowledge; What is evidence-based practice (EBP)? Informatics? | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

6 ..

7) The nurse prescribes strategies and alternatives to assist a patient achieve expected outcomes. Within which American Nurses Association standard is the nurse practicing? 1. Planning 2. Assessment 3. Diagnosis 4. Implementation Answer: 1 Explanation: 1. The American Nurses Association Standards of Practice follow the nursing process. The nurse who prescribes strategies and alternatives to assist a patient achieve expected outcomes is practicing within the standard of planning. 2. Assessment activities include data collection. 3. Diagnosis activities include analyzing data to determine issues. 4. Implementation activities include implementing the identified plan, coordinating care delivery, and employing strategies to promote health and a safe environment. Page Ref: 13 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply professional standards | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

7 ..

8) A patient with a terminal illness is concerned about pain control. If the International Council of Nurses Code of Ethics for Nurses is followed, what should the nurse plan for the patient? 1. Measures to alleviate suffering 2. Modified activities of daily living 3. Enforcement of strict bed rest 4. Dietary interventions to maximize strength Answer: 1 Explanation: 1. The philosophical basis for the International Council of Nurses Code of Ethics for Nurses is the responsibility to promote health, prevent illness, and alleviate suffering. The nurse should plan measures to alleviate the patient's suffering. 2. Modified activities of daily living may not affect pain control. 3. Enforcement of strict bed rest may not affect pain control. 4. Dietary interventions to maximize strength may not affect pain control. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Knowledge and Science; Practice-Know-How; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

8 ..

9) A patient is angry after waiting over an hour for pain medication. What should the nurse respond to the patient that demonstrates clinical reasoning? 1. "I understand your anger and am sorry for the delay. I have your pain medication now." 2. "I had other patients who needed my attention first, so I did a few things before getting the pain medication." 3. "I needed to find out what your medication is and if you can have more when you asked." 4. "It seems that you always ask for pain medication when I am trying to do other things." Answer: 1 Explanation: 1. Clinical reasoning involves complex and multiple cognitive processes, which integrates the unique context of a clinical situation and addresses individual concerns of the patient and family. For the patient who is angry, this statement demonstrates empathy and critical thinking. 2. This statement is not an example of clinical reasoning and would be an inappropriate response. 3. This statement is not an example of clinical reasoning and would be an inappropriate response. 4. This statement is not an example of clinical reasoning and would be an inappropriate response. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Knowledge and Science; Practice-Know-How; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

9 ..

10) The nurse is identifying nursing diagnoses appropriate for a patient's plan of care. What should the nurse use to determine these diagnoses? 1. Diagnostic reasoning 2. Communication techniques 3. Identified outcome criteria 4. Established priorities Answer: 1 Explanation: 1. Making a diagnosis is a complex process, and the nurse uses diagnostic reasoning to choose nursing diagnoses that best define the individual patient's health problems. Diagnostic reasoning is a form of clinical judgment used to make decisions about which label, or diagnosis, best describes the patterns of data. Steps in the process include identifying significant cues, clustering the cues and identifying gaps, drawing conclusions about the present health status, and determining etiologies and categorizing problems. 2. Communication techniques would be needed when conducting the patient assessment. 3. Identification of outcome criteria is a part of the planning phase of the nursing process. 4. Priorities are established during the implementation phase of the nursing process. Page Ref: 8 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

10 ..

11) The nurse plans and implements care for a patient based on nursing knowledge and skills. In which role is the nurse functioning? 1. Caregiver 2. Advocate 3. Educator 4. Leader Answer: 1 Explanation: 1. The caregiver role for the nurse today is both independent and collaborative. Nurses independently make assessments and plan and implement patient care based on nursing knowledge and skills. 2. The nurse functioning as a patient advocate actively promotes the patient's rights to autonomy and free choice. 3. The nurse functioning in the role of educator nurse assesses learning needs, plans and implements teaching methods to meet those needs, and evaluates the effectiveness of the teaching. 4. The nurse functioning in the role of leader directs, delegates, and coordinates nursing activities. Page Ref: 14 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patientcentered care | NLN Competencies: Knowledge and Science; Practice-Know-How; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

11 ..

12) A patient has questions about a required surgical procedure. When performing as a patient advocate, what should the nurse do? 1. Contact the healthcare provider and ask that the procedure be explained to the patient. 2. Explain the procedure to the patient. 3. Document that the patient does not understand the proposed surgical procedure. 4. Instruct the patient in alternatives to the surgical procedure. Answer: 1 Explanation: 1. The nurse as patient advocate actively promotes the patient's rights to autonomy and free choice. The nurse should protect the patient's right to self-determination about the surgical procedure. 2. The nurse should not explain the procedure to the patient. This is not patient advocacy. 3. The nurse should not do anything beyond documenting the patient's lack of understanding about the procedure. 4. The nurse should not provide alternatives to the surgical procedure. Page Ref: 16 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.2. Communicate patient values, preferences, and expressed needs to other members of healthcare team | AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidencebased, patient-centered care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

12 ..

13) The nurse teaches a patient newly diagnosed with type 2 diabetes mellitus about the importance of an annual dilated-retina eye examination and annual urine tests to measure protein levels. Within which role is the nurse functioning? 1. Educator 2. Researcher 3. Advocate 4. Leader Answer: 1 Explanation: 1. The nurse is functioning as an educator by instructing the patient on annual tests to maintain health. 2. As a researcher, the nurse would have a goal to improve the care nurses provide to patients. 3. As an advocate, the nurse actively promotes the patient's rights to autonomy and free choice. 4. As a leader, the nurse manages time, people, and resources by delegating, directing, and coordinating nursing activities. Page Ref: 15 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

13 ..

14) The nurse is providing care within the primary nursing delivery model. Which leadership activities should the nurse perform within this model? Select all that apply. 1. Communicate with patients, families, and other care providers. 2. Serve as the team leader by making assignments and being responsible for all care provided. 3. Make referrals and manage the quality of care to include timeliness and cost. 4. Manage a caseload of patients and the health team members providing care to the patients. 5. Create patient discharge plans. Answer: 1, 5 Explanation: 1. When providing care to patients within the primary nursing care delivery model, leadership activities of the nurse include communicating with patients, families, and other care providers. 2. In the team nursing care delivery model, leadership activities of the nurse include serving as the team leader, making assignments, and being responsible for all care provided. 3. In the transitional care coordination model, leadership activities of the nurse include making referrals and managing the quality of care to include timeliness and cost. 4. In the transitional care coordination model, leadership activities of the nurse include managing a caseload of patients and the health team members providing care to the patients. 5. When providing care to patients within the primary nursing care delivery model, leadership activities of the nurse include creating discharge plans. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: I.4. Use written, verbal, non-verbal and emerging technology methods to communicate effectively | NLN Competencies: Quality and Safety; Practice-Know-How; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

14 ..

15) The nurse is using a specific process to plan smoking cessation activities for a patient. What is this nurse most likely using to plan the care for this patient? 1. Nursing process 2. Critical pathways 3. Evidence-based practice 4. Variance analysis Answer: 1 Explanation: 1. The nursing process is a series of critical-thinking and clinical reasoning activities that nurses use to provide care to patients. The purpose of care may be to promote wellness, restore health, or facilitate coping with a disability or death. 2. Critical pathways are used primarily to manage disease conditions. 3. Evidence-based practice is used primarily to manage disease conditions. 4. Variance analyzing implies the use of statistics-based research. Page Ref: 6-7 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

15 ..

16) The nurse working on a quality improvement study wants to evaluate a patient care process. What should the nurse use to evaluate this process? 1. Nursing process 2. Critical pathway 3. Variance analysis 4. Evidence-based practice Answer: 1 Explanation: 1. The nursing process can serve as a framework for the evaluation of quality care. 2. The use of critical pathways would not provide the best, recommended means to evaluate a patient care process. 3. The use of variance analysis would not provide the best, recommended means to evaluate a patient care process. 4. The use of evidence-based practice would not provide the best, recommended means to evaluate a patient care process. Page Ref: 20 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV.A.1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice | AACN Essentials Competencies: II.1. Apply leadership concepts, skills, and decision making in the provision of high-quality nursing care; healthcare team coordination; and the oversight and accountability for care delivery in a variety of settings | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

16 ..

17) The nurse is reviewing the outcome of care that was provided to a patient. Which nursing process step is the nurse implementing? 1. Evaluation 2. Assessment 3. Implementation 4. Planning Answer: 1 Explanation: 1. The evaluation step allows the nurse to determine whether the plan was effective and whether to continue, revise, or terminate the plan. The outcome criteria that were established during the planning step provide the basis for evaluation. 2. During the assessment phase, the nurse is actively collecting data. 3. Implementation is the phase of the nursing process during which the nurse performs interventions. 4. Determining the needs of the patient and devising a plan of action take place during the planning phase. Page Ref: 11-12 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.C.10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Knowledge and Science; Practice-Know-How; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

17 ..

18) A patient says, "I have pain in my leg when I stand too long." As which type of data should the nurse categorize this information? 1. Subjective 2. Evaluative 3. Qualitative 4. Objective Answer: 1 Explanation: 1. Information that is perceived only by the person experiencing it is subjective data. 2. Evaluative data is used to assess responses to care. 3. Qualitative data refers to the presence or absence of a factor. 4. Objective data can be measured by someone or something other than the patient. Page Ref: 8 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview; implementation of care plan; and evaluation of care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

18 ..

19) While providing care, the nurse stops to assess a new patient problem. What type of assessment is the nurse conducting? 1. Focused 2. Initial 3. Objective 4. Subjective Answer: 1 Explanation: 1. Focused assessments are ongoing and continuous, occurring whenever the nurse interacts with the patient. In a focused assessment, data are gathered about an identified or potential problem and are used to evaluate nursing actions and make decisions about whether to continue or change interventions to meet outcomes. Focused assessments enable the nurse to identify responses to a disease process or treatment modality not present during the initial assessment, and to identify new problems. 2. The initial assessment refers to the first interaction. 3. Subjective assessment is not indicated in this scenario. 4. Objective assessment is not indicated in this scenario. Page Ref: 8 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.1. Elicit patient values, preferences, and expressed needs as part of clinical interview; implementation of care plan, and evaluation of care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

19 ..

20) At the completion of an assessment, the nurse chooses a nursing diagnosis that best defines the patient's health problems. Which type of clinical judgment should the nurse use at this time? 1. Diagnostic reasoning 2. Evidence-based practice 3. Critical pathway 4. Nursing process Answer: 1 Explanation: 1. Diagnostic reasoning is a form of clinical judgment used to make decisions about which diagnostic label best describes the patterns of patient data. 2. Evidence-based practice refers to the implementation of care initiatives that have been supported by research. 3. A critical pathway is a healthcare plan developed to provide care with a multidisciplinary, managed action focus. 4. The nursing process is a series of critical thinking and clinical reasoning activities nurses use as they provide care to patients. Page Ref: 8 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

20 ..

21) The nurse is creating outcome criteria for identified nursing diagnoses for a patient. What characteristics should the nurse include when creating the criteria? 1. Patient-specific, time-specific, and measurable 2. Constructed as nursing goals 3. Structured as statements 4. Focus on psychomotor actions Answer: 1 Explanation: 1. Outcome criteria for nursing diagnoses are patient-centered, time-specific, and measurable. They are classified into three domains: cognitive, affective, and psychomotor. 2. The focus of the outcome criteria is the patient, not the nurse. 3. While the outcome criteria are often written as statements, this option does not encompass all of the criteria that are to be included. 4. Outcome criteria are not limited to psychomotor skills; they may also be cognitive or affective. Page Ref: 8-9 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.8. Describe the limits and boundaries of therapeutic patient-centered care | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Quality and Safety; Practice-Know-How; Contribute to assessment of outcome achievement | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

21 ..

22) The nurse is implementing a plan of care for a patient. After providing care, what should the nurse do as the final step in the process? 1. Document 2. Reassess the patient 3. Measure vital signs 4. Provide report to the charge nurse Answer: 1 Explanation: 1. Documenting interventions is the final component of implementation as well as a legal requirement. 2. Ongoing assessment of the patient is an essential component of implementation, but it is not the final step. 3. Measuring vital signs can be completed at any time and not necessarily at the end of implementing the plan of care. 4. Providing report is an ongoing process and is not necessarily completed after implementing the plan of care. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: VI.B.4. Document and plan patient care in an electronic health record | AACN Essentials Competencies: IV.4. Understand the use of CIS (clinical information systems) systems to document interventions related to achieving nurse sensitive outcomes | NLN Competencies: Knowledge and Science; Practice-Know-How; Document via electronic health records; use software applications related to nursing practice | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

22 ..

23) A patient care issue has been raised about the actions taken by a nurse who provided care to a patient whose healthcare decisions were considered controversial. What should the nurse manager consult to protect the patient and evaluate the care in question? 1. Nursing Code of Ethics 2. Hospital quality improvement guidelines 3. Nurse Practice Act 4. Critical pathway Answer: 1 Explanation: 1. An established code of ethics is one criterion that defines a profession. Ethics are principles of conduct. Codes of ethics for nurses provide a frame of reference for ideal nursing behaviors that are congruent with the principles expressed in the Code for Nurses. 2. Quality improvement uses data to monitor the outcomes of care and the processes used to deliver that care. 3. The Nurse Practice Act provides the standards for an individual state's stance on the nurse's scope of practice. 4. A critical pathway is a healthcare plan developed to provide care with a multidisciplinary, managed action focus. Page Ref: 12 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal, or unethical care practices | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

23 ..

24) The nurse is preparing a patient to go home. Which skill should the nurse use when preparing this patient? 1. Familiarity with adult learning principles 2. Ability to follow written orders 3. Ability to use critical thinking 4. Ability to support patient decision making Answer: 1 Explanation: 1. The nurse will function as an educator when preparing a patient for discharge. To do this adequately, the nurse will need to have some level of familiarity with adult learning principles to provide effective patient education and evaluate the outcome. 2. Following written orders is considered a basic caregiver skill. 3. Using critical thinking would be considered a basic caregiver skill. 4. The ability to support patient decision making relates to the role of patient advocate. Page Ref: 16 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

24 ..

25) The nurse is preparing to provide patient care information to a group of unlicensed assistive personnel. Which type of care delivery system is this nurse most likely using to provide patient care? 1. Team nursing 2. Functional nursing 3. Primary nursing 4. Case management Answer: 1 Explanation: 1. Team nursing is practiced by teams of healthcare providers with various levels of education, including unlicensed assistive personnel. Team members work together and provide the care for which they are individually trained. 2. Functional nursing is not a recognized term. 3. In primary nursing, total nursing care is provided by the assigned nurse. 4. The focus of case management is meeting the needs and care of a group of patients, with concurrent goals of maximized outcomes and cost containment. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e., scope of discipline, education, and licensure requirements) | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

25 ..

26) A nurse has delegated the collection of vital signs, including blood pressure readings, to two unlicensed assistive personnel. What is the nurse's responsibility for the delegated care? 1. The nurse is accountable for the care that was delegated. 2. The nurse is not responsible for these vital signs. 3. The nurse is not accountable for these vital signs. 4. The nurse is responsible for re-measuring all the vital signs. Answer: 1 Explanation: 1. When the nurse delegates nursing care activities to another person, that person is authorized to act in the place of the nurse, while the nurse retains accountability for the activities performed. 2. The nurse retains responsibility/accountability for the vital signs. 3. The nurse is accountable for reviewing the data collected and ensuring it is done appropriately. 4. The purpose of delegation is to share tasks appropriately, not to increase the workload of the primary nurse. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.B.5. Assume role of team member or leader based on the situation | AACN Essentials Competencies: VI.1. Compare/contrast the roles and perspectives of the nursing profession with other care professionals on the healthcare team (i.e., scope of discipline, education, and licensure requirements) | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

26 ..

27) The nurse manager completes chart audits for a specific group of patients. What should the manager do with this information? 1. Create an action plan to address any negative findings. 2. Share it with the hospital administrator. 3. Submit it to the agency's accrediting body. 4. Place it in a file to compare with the next set of audits. Answer: 1 Explanation: 1. The results of quality assurance audits can be used to develop a plan of action to resolve differences or issues with patient care. Nurses use the information if it will have a positive impact on the nursing practice. 2. There is no real purpose to sharing the results of a quality assurance audit with the hospital administrator. 3. While the accrediting body of an institution may encourage quality improvement activities, there is no reason to provide the chart audit results. 4. Nurses use the information if it will have a positive impact on the nursing practice. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV.B.5. Use quality measures to understand performance | AACN Essentials Competencies: II.10. Use improvement methods, based on data from the outcomes of care processes, to design and test changes to continuously improve the quality and safety of healthcare | NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.1 Describe the core competencies for healthcare professionals: Patientcentered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 1. Demonstrate use of the core competencies for healthcare professionals in nursing practice.

27 ..

28) The nurse reviews the role of advocacy with a group of new graduate nurse employees. Which statement by a graduate nurse indicates the need for further education? 1. "Patient advocates have the authority to make decisions for the patient." 2. "Being a patient advocate entails making efforts to improve patient outcomes." 3. "Providing education to the patient and family is a key way to be a positive patient advocate." 4. "Communicating patient needs to the members of the healthcare team is a role of the patient advocate." Answer: 1 Explanation: 1. The nurse who serves as a patient advocate may assist and support the patient in decision making. The nurse cannot make decisions for the patient. 2. This is an element of being a successful patient advocate. 3. This is an element of being a successful patient advocate. 4. This is an element of being a successful patient advocate. Page Ref: 16 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.2. Communicate patient values, preferences, and expressed needs to other members of healthcare team | AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidencebased, patient-centered care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

28 ..

29) The director of nursing is reviewing situations that require attention. Which situation is an ethical dilemma that might need to be analyzed by the hospital Ethics Committee? 1. A 20-year-old male patient with an opportunistic disease is HIV positive and does not want to share this information with sexual partners. 2. The nurse-patient ratio is 5:1 on a medical-surgical care area. 3. A nurse inexperienced with electrocardiogram interpretation was assigned to the telemetry unit to provide care. 4. Nursing staff provide medication to patients after doses are dropped on the floor. Answer: 1 Explanation: 1. A dilemma is a choice between two unpleasant, ethically troubling alternatives. Nurses who provide medical-surgical nursing care face dilemmas almost daily. Many commonly experienced dilemmas involve confidentiality, patient rights, and issues of dying and death. Nurses respect the right to confidentiality of patient information found in the patient's record or secured during interviews. An individual's right to privacy and confidentiality creates a dilemma when it conflicts with the nurse's right to information that may affect personal safety. The law in most states mandates that HIV test results can be given to another person only with the patient's written consent. Many healthcare providers believe that this law violates their own right to personal safety. 2. This situation is not a dilemma but may violate standards of care or standards of practice. 3. This situation is not a dilemma but may violate standards of care or standards of practice. 4. This situation is not a dilemma but may violate standards of care, codes of ethics, or standards of practice. Page Ref: 13-14 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

29 ..

30) The nurse accepts tickets to a sporting event from a patient in exchange for free home care for 1 week. Which standards did the nurse violate? Select all that apply. 1. HIPAA 2. ANA standards 3. Professional boundaries 4. State nurse practice acts 5. Standards pertinent to specific hospital protocols Answer: 3, 4 Explanation: 1. HIPAA involves violations of patient confidentiality. 2. A violation of ethics in the ANA Standards of Care would not apply here. 3. Professional boundaries are the borders between the vulnerability of the patient and the power of the nurse. It is vital that nurses recognize this relationship and establish boundaries to safely and effectively meet the patient's needs. Confusion between the needs of the nurse and those of the patient can result in boundary violations. 4. Professional boundaries are outlined in individual state nurse practice acts. 5. Hospital protocols are not identified in the question; however, the nurse's action violates a professional boundary. Page Ref: 13 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VIII.1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

30 ..

31) A seasoned nurse does not want to assist nursing students during clinical rotations and often obstructs the students' learning process. Which standard is this nurse violating? 1. ICN Code of Ethics 2. ANA Standards of Professional Performance 3. ANA Code of Ethics 4. State practice acts Answer: 2 Explanation: 1. The ICN Code of Ethics for Nurses helps guide nurses in setting priorities, making judgments, and taking action when they face ethical dilemmas in clinical practice. 2. The nurse is violating the standards of leadership and collaboration by refusing to assist the students during the learning process. 3. The nurse is not violating the Code of Ethics. 4. The nurse is not violating the state nurse practice act. Page Ref: 13 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.C.6. Value teamwork and the relationships upon which it is based | AACN Essentials Competencies: VIII.1. Demonstrate the professional standards of moral, ethical, and legal conduct | NLN Competencies: Context and Environment; Knowledge; Code of Ethics; regulatory and professional standards | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.3 Explain the importance of nursing and interprofessional codes of ethics, standards of practice, and legal and ethical issues as guidelines for clinical nursing practice. MNL Learning Outcome: 3. Integrate nursing and interprofessional codes of ethics, standards of practice, and legal and ethical guidelines in clinical practice.

31 ..

32) The nurse attends interprofessional meetings to discuss the plan of care for a trauma patient who has been transferred to the medical-surgical unit. In what role is this nurse functioning? 1. Caregiver 2. Team leader 3. Delegate 4. Advocate Answer: 4 Explanation: 1. The caregiver works independently and collaboratively with the patient. 2. Team leaders are nurses who are participating in roles of leadership in that they manage time, people, resources, and the environment to ensure that staff is able to provide the proper care. 3. Delegates are nurses who are responsible for completing care as assigned. 4. The nurse as advocate actively promotes the patient's rights to autonomy and free choice. The nurse will communicate with other healthcare team members and assist and support patient decision making. Page Ref: 16 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.2. Communicate patient values, preferences, and expressed needs to other members of healthcare team | AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidencebased, patient-centered care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

32 ..

33) The director of nursing is planning an initiative to improve the quality and safety of patient care. After reviewing the Triple Aim approach, which action should the director recommend? Select all that apply. 1. Improve the patient care experience. 2. Maximize positive outcomes. 3. Reduce the per capita costs of healthcare. 4. Implement evidence-based practice. 5. Support nursing continuing education plans. Answer: 1, 2, 3 Explanation: 1. The Institute of Health Improvement Triple Aim has three objectives. Improve patient care experience is one of these objectives. 2. The Institute of Health Improvement Triple Aim has three objectives. Maximize positive outcomes is one of these objectives. 3. The Institute of Health Improvement Triple Aim has three objectives. Contain costs is one of these objectives. 4. Implementing evidence-based practice is not a Triple Aim objective. 5. Supporting nursing continuing education plans is not a Triple Aim objective. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV.B.5. Use quality measures to understand performance | AACN Essentials Competencies: II.11. Employ principles of quality improvement, healthcare policy, and cost-effectiveness to assist in the development and initiation of effective plans for the microsystem and/or system-wide practice improvements that will improve the quality of healthcare delivery | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

33 ..

34) The nurse would like to do a research project that focuses on vending machine choices that patients prefer. What should the nurse question before proceeding with this research study? 1. Is the research valid? 2. Will this promote patient independence? 3. Is this a project that would add value to the hospital experience? 4. Does this research contribute to patient care? Answer: 4 Explanation: 1. To be relevant, nursing research must have a goal to improve the care that nurses provide patients. This means that all nurses must consider the researcher role to be integral to nursing practice. The research might be valid; however, it does not improve patient care. 2. To be relevant, nursing research must have a goal to improve the care that nurses provide patients. This means that all nurses must consider the researcher role to be integral to nursing practice. The research might promote patient independence but may not improve patient care. 3. To be relevant, nursing research must have a goal to improve the care that nurses provide patients. This means that all nurses must consider the researcher role to be integral to nursing practice. The research might add value to the hospital experience but may not improve patient care. 4. To be relevant, nursing research must have a goal to improve the care that nurses provide patients. This means that all nurses must consider the researcher role to be integral to nursing practice. Page Ref: 20 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities | AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice | NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

34 ..

35) The nurse is identifying nursing diagnoses for a patient's care. In which order should the nurse complete this process? Place in order the steps of the process. Choice 1. Draw conclusions about the present health status. Choice 2. Determine etiologies and categorize problems. Choice 3. Cluster cues and identify data gaps. Choice 4. Verify the problem or diagnoses. Choice 5. Recognize significant cues. Answer: 5, 3, 1, 2, 4 Explanation: Choice 1. Based upon the data clusters and gaps identified, the patient's health status can be determined. Choice 2. Once the patient's present health status is determined, the etiology of problems can be identified and then categorized. Choice 3. After cues are identified, they are to be clustered so that data gaps can be identified. Choice 4: The final step is to verify the patient's problems and finalize the appropriate diagnoses. Choice 5. When identifying nurse diagnoses, significant cues should be identified first. Page Ref: 9 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives, and patient preferences in planning, implementing, and evaluating outcomes of care | NLN Competencies: Knowledge and Science; Practice-KnowHow; Translate research into practice in order to promote quality and improve practices | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

35 ..

36) The nurse is hired to coordinate care in a community health clinic that opened after the implementation of the Affordable Care Act. Which types of care should the nurse expect to provide? Select all that apply. 1. Health promotion 2. Disease prevention 3. Chronic disease management 4. Rehabilitation 5. Palliative care Answer: 1, 2, 3 Explanation: 1. The original intent of the ACA continues to influence healthcare policy and reimbursement, and it is changing provider practice and the environment. The nursing profession is well positioned to respond to demands of a transitioning healthcare system that emphasize health promotion. 2. The original intent of the ACA continues to influence healthcare policy and reimbursement, and it is changing provider practice and the environment. The nursing profession is well positioned to respond to demands of a transitioning healthcare system that emphasize disease prevention. 3. The original intent of the ACA continues to influence healthcare policy and reimbursement, and it is changing provider practice and the environment. The nursing profession is well positioned to respond to demands of a transitioning healthcare system that emphasize management of chronic disease. 4. Rehabilitation is not a new model of care that will be provided in a community health clinic. 5. Palliative care is not a new model of care that will be provided in a community health clinic. Page Ref: 2 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

36 ..

37) The nurse manager is evaluating the use of evidence-based practice guidelines to guide care on a patient care area. Which observation indicates that these guidelines are being used appropriately? Select all that apply. 1. Guidelines are posted on the staff bulletin board in the break room. 2. A guideline was quoted in a narrative note in a patient's medical record. 3. A guideline is placed in the Kardex to support the use of a nursing diagnosis for a patient's health problem. 4. Guidelines are accessed through the clinical documentation system by nurses prior to writing patient care plans. 5. A guideline was referenced prior to implementing skin care interventions for a patient prone to pressure ulcer formation. Answer: 2, 3, 4, 5 Explanation: 1. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare. Posting the guidelines on the staff bulletin board does not indicate that they are being used appropriately. 2. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare. Basing patient care on an evidence-based guideline indicates that it is being used appropriately. 3. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare. Placing a copy of an evidence-based guideline in the Kardex to support a particular nursing diagnosis indicates that it is being used appropriately. 4. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare. Observing staff access evidence-based guidelines through the clinical documentation system indicates they are being used appropriately. 5. Evidence-based practice integrates best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare. Referring to an evidence-based guideline before planning skin care interventions indicates the guideline is being used appropriately. Page Ref: 5 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III.B.6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice | AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice | NLN Competencies: Knowledge and Science; Knowledge; What is evidence-based practice (EBP)? Informatics? | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1.1 Describe the core competencies for healthcare professionals: Patientcentered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 1. Demonstrate use of the core competencies for healthcare professionals in nursing practice. 37 ..

38) An interprofessional team is meeting to create a care bundle to prevent the development of contractures in patients with limb paralysis from neurological health problems. Which action should the committee members include when creating this care bundle? Select all that apply. 1. Define the patient population 2. Identify three to five interventions 3. Ensure the elements of the bundle are independent 4. Ensure the bundle elements are descriptive 5. Mandate that the bundle elements are prescriptive Answer: 1, 2, 3, 4 Explanation: 1. Care bundles are interprofessional care standards that pull together a short list of interventions and treatments that are already recommended and are generally accepted in national guidelines. The bundle is used with a defined patient population in one location. 2. The bundle has three to five interventions (elements), with strong clinician agreements. 3. Each bundle is relatively independent. The bundle is developed so that if one of the interventions of care is not implemented it will not affect whether other bundle elements are implemented. 4. Bundle elements should be descriptive rather than prescriptive, to allow for local customization and appropriate clinical judgment. 5. Bundle elements should be descriptive rather than prescriptive. Page Ref: 11 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: III.B.6. Participate in structuring the work environment to facilitate integration of new evidence into standards of practice | AACN Essentials Competencies: III.9. Describe mechanisms to resolve identified practice discrepancies between identified standards and practice that may adversely impact patient outcomes | NLN Competencies: Context and Environment; Knowledge; Codes of ethics, regulatory and professional standards, ethical decision-making models, scope of practice considerations, principles of informed consent, confidentiality, patient self-determination | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

38 ..

39) The nurse is coordinating care for patients within a patient-centered medical home (PCMH). Which action should the nurse prepare to complete when functioning in this role? Select all that apply. 1. Communicate with the patient after discharge. 2. Monitor the implementation of the plan of care. 3. Manage the accuracy, timeliness, and cost of care. 4. Develop the plan of care with the patient and family. 5. Collaborate with the patient to implement the plan of care. Answer: 1, 2, 3, 5 Explanation: 1. The nurse functioning as a care coordinator within a PCMH will be in contact with the patients after discharge to ensure continuity of care and health maintenance. 2. The nurse functioning as a care coordinator within a PCMH will monitor the implementation of the patient's plan of care. 3. The nurse functioning as a care coordinator within a PCMH manages the quality of care provided, including accuracy, timeliness, and cost. 4. The PCMH team is led by the patient's primary care provider, who is responsible for leading the development of the plan of care with the patient and the family. 5. The nurse functioning as a care coordinator within a PCMH collaborates with the patient to implement the plan of care. Page Ref: 17 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: IV.A.1. Describe strategies for learning about the outcomes of care in the setting in which one is engaged in clinical practice | AACN Essentials Competencies: II.11. Employ principles of quality improvement, healthcare policy, and cost-effectiveness to assist in the development and initiation of effective plans for the microsystem and/or systemwide practice improvements that will improve the quality of healthcare delivery | NLN Competencies: Teamwork; Knowledge; Scope of practice, roles, and responsibilities of healthcare team members, including overlaps | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.4 Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 4. Consider the various role of the nurse as in medical-surgical nursing practice.

39 ..

40) The nurse is using clinical reasoning to plan patient care. Which foundational source of knowledge should the nurse use? Select all that apply. 1. Know the profession 2. Know self 3. Know the case 4. Know the patient 5. Know the patient's health insurance Answer: 1, 2, 3, 4 Explanation: 1. Knowing the profession means the nurse has knowledge of standards of practice, scope of practice, competencies, skills, and the role of nurses. 2. Knowing self means knowledge of one's own strengths, limitations, skills, experience, assumptions, preconceptions, learning, and other needs. 3. Knowing the case means knowledge of pathophysiology, patterns that exist in typical cases, evidence-based practices relevant to appropriate patient population, predicted trajectory, and predictable patient responses. 4. Knowing the patient means knowledge of a patient's baseline data, patterns that exist in laboratory or other data, and patterns in physiologic responses to pathology and treatment. 5. Knowing the patient's health insurance is not a foundational source of knowledge. Page Ref: 6 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: I.7. Integrate the knowledge and methods of a variety of disciplines to inform decision making | NLN Competencies: Context and Environment; Knowledge; Change, uncertainty, complexity theories, impact of continual knowledge explosion and constant evolution of technology, decision making in uncertainty, management of conflicting information, blurring of role boundaries, and the resultant uncertainty about role expectation | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.2 Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 2. Recognize the skills necessary for clinical reasoning when using the nursing process in patient care.

40 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 2 Health and Illness Care of Adults 1) The nurse is caring for a patient with heart failure. What should the nurse include when planning holistic care for this patient? 1. Spiritual needs 2. Measuring intake and output 3. Daily weights 4. Ambulating with assistance Answer: 1 Explanation: 1. Holistic healthcare considers all aspects of an individual (physical, psychosocial, cultural, spiritual, and intellectual) as essential components of individualized care. 2. Measuring intake and output meets the patient's physical needs and would not address holistic needs. 3. Daily weights focus solely on the patient's physical needs and would not address holistic needs. 4. Ambulating with assistance focuses solely on the patient's physical needs and would not address holistic needs. Page Ref: 25 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Religious and Spiritual Influences on Health Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

1 ..

2) A patient reports never experiencing major illnesses and has enjoyed good health without much effort. How should the nurse identify this patient's definition of health? 1. Absence of disease 2. Effortless 3. Fortunate 4. Integrated method of functioning Answer: 1 Explanation: 1. The patient is defining health as being the absence of disease because of not experiencing any major illnesses and not expending much effort to do so. 2. The nurse has no way of knowing if the patient believes health is effortless. 3. The nurse has no way of knowing if the patient believes health is fortunate. 4. An integrated method of functioning is the definition of wellness which the patient is not describing. Page Ref: 25 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

2 ..

3) During an assessment, the nurse learns that a patient has a genetic predisposition to the development of several disease processes. Which illness should the nurse realize is associated with genetic makeup? 1. Cancer 2. Hypertension 3. Osteoporosis 4. Myocardial infarction Answer: 1 Explanation: 1. Chronic illnesses that are associated with genetic makeup include sickle cell disease, hemophilia, diabetes mellitus, and cancer. 2. Hypertension is associated with a cultural group. 3. Osteoporosis is associated with a cultural group. 4. Myocardial infarction is associated with age and lifestyle factors. Page Ref: 25 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems | NLN Competencies: Relationship-Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

3 ..

4) The nurse is assessing a patient who is a Native American. For which health problem should the nurse assess the patient? 1. Diabetes mellitus 2. Eye disorders 3. Hypertension 4. Osteoporosis Answer: 1 Explanation: 1. Diabetes mellitus is among the leading causes of illness in Native Americans. This is what the nurse should include in the assessment of this patient. 2. Eye disorders are more common in Chinese Americans. 3. Hypertension is more common in African Americans. 4. Osteoporosis is more common in Caucasian women of small stature and Scandinavian heritage. Page Ref: 26 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems | NLN Competencies: Relationship-Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

4 ..

5) During an assessment, a patient reports being lactose intolerant. Within which cultural group is this food intolerance common? 1. Mexican Americans 2. Scandinavian Americans 3. Indian Americans 4. Mediterranean Americans Answer: 1 Explanation: 1. Mexican Americans, African Americans, Native Americans, and Asians may be lactose intolerant. 2. Lactose intolerance is not common in Scandinavian Americans. 3. Lactose intolerance is not common in Indian Americans. 4. Lactose intolerance is not common in Mediterranean Americans. Page Ref: 26 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems | NLN Competencies: Relationship-Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

5 ..

6) A patient with a respiratory illness is a factory worker and uses public transportation to get to work. Which will be impacted by the patient's socioeconomic status? 1. Lifestyle 2. Cognitive abilities 3. Education level 4. Developmental level Answer: 1 Explanation: 1. Lifestyle and environmental influences are affected by one's income level. 2. Cognitive development affects whether people view themselves as healthy or ill and may affect their health practices. 3. Educational level affects the ability to understand and follow guidelines for health. 4. Developmental level is not related to socioeconomic status. Page Ref: 26 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems | NLN Competencies: Relationship-Centered Care; Knowledge; Factors that contribute to or threaten health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

6 ..

7) The nurse is reviewing the goals for Healthy People 2020 with a group of patients in an outpatient clinic. What should the nurse include in this presentation? Select all that apply. 1. Attain high-quality, longer lives free of preventable disease, disability, injury, and premature death. 2. Achieving health equity, eliminating disparities, and improving the health of all groups. 3. Creating social and physical environments that promote good health for all. 4. Promoting healthy development and healthy behaviors across every stage of life. 5. Achieving a body weight 20% less than recommended in current standardized height/weight charts. Answer: 1, 2, 3, 4 Explanation: 1. Attaining high-quality, longer lives free of preventable disease, disability, injury, and premature death is one of the Healthy People 2020 goals and should be included in the presentation. 2. Achieving health equity, eliminating disparities, and improving the health of all groups is one of the Healthy People 2020 goals and should be included in the presentation. 3. Creating social and physical environments that promote good health for all is one of the Healthy People 2020 goals and should be included in the presentation. 4. Promoting healthy development and healthy behaviors across every stage of life is one of the Healthy People 2020 goals and should be included in the presentation. 5. Achieving a body weight 20% less than recommended in current standardized height/weight charts is not a Healthy People 2020 goal and might be considered dangerous. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention; chronic disease management | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 2.2 Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 2. Recognize the health risks of individuals across the lifespan, families, and communities and the role of nursing in health promotion and maintenance.

7 ..

8) The nurse is instructing a patient on nutritional needs by using MyPlate. What should the nurse emphasize when using this food guide? 1. Consuming nutrient-dense foods and beverages. 2. Ways to limit exposure to carcinogens 3. Activities to reduce the onset of diabetes mellitus 4. Avoiding overuse of aerobic exercise Answer: 1 Explanation: 1. The U.S. Department of Agriculture provides a general guideline for what to eat each day, illustrated in MyPlate. One overarching concept for this guide is to focus on consuming nutrient-dense foods and beverages. 2. MyPlate was not created to instruct patients on ways to limit exposure to carcinogens. 3. MyPlate was not created to reduce the onset of diabetes mellitus. 4. MyPlate was not created to avoid the overuse of aerobic exercise. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention; chronic disease management | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 2.2 Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 2. Recognize the health risks of individuals across the lifespan, families, and communities and the role of nursing in health promotion and maintenance.

8 ..

9) A patient asks for suggestions to help improve current health status. What should the nurse instruct this patient? 1. Participate in a continuous physical activity for 30 minutes, 5 or more days each week. 2. Obtain sun exposure every day. 3. Reduce tobacco use. 4. Sleep at least 6 hours each night. Answer: 1 Explanation: 1. Practices for healthy living include participating in a continuous physical activity for 30 minutes 5 or more days each week. 2. Sun exposure should be limited and should always involve application of a sunscreen. 3. Smoking and the use of tobacco products should be eliminated, not just reduced. 4. The patient should be instructed to sleep 7 to 8 hours each day. Page Ref: 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; apply health promotion/disease prevention strategies; apply health policy | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.2 Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 2. Recognize the health risks of individuals across the lifespan, families, and communities and the role of nursing in health promotion and maintenance.

9 ..

10) A patient reports drinking four alcoholic beverages every day and smoking one pack of cigarettes. Which is this patient predisposed to develop? 1. Disease 2. Illness 3. Injury 4. Infection Answer: 1 Explanation: 1. The term disease describes an alteration in structure and function of the body or mind. One cause of disease is exposure to chemicals such as alcohol and tobacco. Ingesting four alcoholic beverages and smoking one pack of cigarettes per day exposes the body to chemicals that can lead to the development of a disease. 2. An illness is a person's response to a disease and is highly individualized. 3. There is not enough information to determine if the alcohol and cigarettes will cause the patient to develop an injury. 4. There is not enough information to determine if the alcohol and cigarettes will cause the patient to develop an infection. Page Ref: 36 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention, chronic disease management | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

10 ..

11) A patient reports a new onset of a health problem. Which is the primary reason for a patient to seek medical attention? 1. Pain 2. Bleeding 3. Vomiting 4. Fatigue Answer: 1 Explanation: 1. The subjective symptom of pain is the primary reason people seek healthcare. 2. Bleeding is an objective symptom that varies with the disease process. 3. Vomiting is an objective symptom that varies with the disease process. 4. Fatigue is a subjective symptom that varies with the disease process. Page Ref: 36 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.C.9. Recognize that patient expectations influence outcomes in management of pain or suffering | AACN Essentials Competencies: IX.8. Implement evidencebased nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness. 12) While being treated for one disease process, a patient begins demonstrating manifestations of another disease process. Which type of disease is the patient experiencing? 1. Iatrogenic 2. Communicable 3. Congenital 4. Degenerative Answer: 1 Explanation: 1. An iatrogenic disease is caused by medical therapy. 2. A communicable disease spreads from one person to another. 3. A congenital disease exists at or before birth. 4. A degenerative disease results from the deterioration or impairment of organs or tissues. Page Ref: 37 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness 11 ..

behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness. 13) A patient reports feeling fine even after being diagnosed with chronic kidney failure. What is the patient likely to manifest? 1. Signs of an illness 2. An iatrogenic disease 3. A psychosomatic illness 4. An idiopathic disorder Answer: 1 Explanation: 1. An illness is a person's response to a disease. The person responds to personal perception of the disease and to the perception of others. Because the patient is diagnosed with chronic kidney failure, signs of an illness are likely to manifest. 2. An iatrogenic disease is caused by medical therapy. 3. Psychosomatic illnesses are characterized by physiologic symptoms caused by mental or emotional disturbance. 4. An idiopathic disorder has no known cause. Page Ref: 36 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

12 ..

14) A patient reports not feeling well for a few days and has been using an over-the-counter medication without improvement. Which illness behavior is this patient demonstrating? 1. Seeking medical care 2. Experiencing symptoms 3. Assuming the sick role 4. Assuming a dependent role Answer: 1 Explanation: 1. The patient is reporting not feeling well, which describes the behavior of seeking medical care. 2. Experiencing symptoms occurs when the patient realizes feelings of being unwell. 3. Assuming the sick role occurs after seeking medical care. 4. Assuming a dependent role occurs upon hospitalization. Page Ref: 38 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

13 ..

15) A patient wants to be discharged to home and resume normal activities of daily living. In which stage of illness behavior is the patient entering? 1. Achieving recovery and rehabilitation 2. Seeking medical care 3. Assuming a dependent role 4. Experiencing symptoms Answer: 1 Explanation: 1. Achieving recovery and rehabilitation is the final stage of an acute illness and occurs when the patient gives up the dependent role and resumes normal activities and responsibilities. 2. Seeking medical care occurs when the patient sees a healthcare provider for diagnosis of an illness. 3. The patient assumes a dependent role when entering the hospital for care. 4. Experiencing symptoms is the first stage of an acute illness. Page Ref: 38 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

14 ..

16) A patient with a chronic illness is not currently experiencing any symptoms and plans to stop following the identified course of care because the disease is cured. How should the nurse respond to this patient? 1. "The treatment plan is the reason you are not experiencing symptoms, so it would be best if you did not stop the plan." 2. "That does sound like a good idea." 3. "You can always resume the plan if the symptoms return." 4. "Plan to wean yourself off the treatment plan and not discontinue it all at once." Answer: 1 Explanation: 1. Patients with a chronic illness need to learn how to manage an ongoing treatment plan even in periods of remission. The treatment plan is the reason the patient is not experiencing any symptoms and the patient should be encouraged to follow the plan. 2. The nurse should not encourage the patient to stop the treatment plan by agreeing that it is a good idea. 3. The nurse should not say that the plan can always be resumed if the symptoms return. 4. The nurse should not suggest that the patient make any alterations in the treatment plan such as weaning off the plan. Page Ref: 39 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.C.1. Value seeing healthcare situations "through patients' eyes" | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

15 ..

17) The nurse is planning care for a patient with a chronic illness. What intervention should the nurse include in the plan of care? 1. Instruct on ways to minimize the impact of the chronic illness. 2. Encourage to seek medical care weekly. 3. Limit activities until symptoms subside. 4. Suggest lifestyle alterations to prepare for more challenging symptom management in the future. Answer: 1 Explanation: 1. Nursing interventions for the person with a chronic illness include modifying lifestyle to adapt to and minimize the impact of the disease. 2. Encouraging the patient to seek medical care weekly does not support effective interaction with the healthcare system on an ongoing basis. 3. Limiting activities until symptoms subside does not improve well-being and quality of life. 4. Suggesting lifestyle alterations to prepare for more challenging symptom management in the future does not improve well-being or quality of life. Page Ref: 39 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.C.1. Value seeing healthcare situations "through patients' eyes" | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality and Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

16 ..

18) The nurse is planning an education session to discuss primary levels of disease prevention. Which topics should the nurse include in this presentation? 1. Elimination of smoking and alcohol use 2. Locations for diabetes screening 3. Schedule colonoscopy examinations as prescribed 4. Use of available community rehabilitation facilities Answer: 1 Explanation: 1. Primary prevention involves activities to prevent illness and disease and includes smoking cessation and abstinence from alcohol. 2. Screening activities such as glucose testing are a form of secondary prevention. 3. Screening activities such as colonoscopy examinations are a form of secondary prevention. 4. Rehabilitation activities are considered a tertiary level of prevention. Page Ref: 40 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

17 ..

19) The nurse is planning interventions to meet a patient's tertiary care needs. Which would be applicable for the patient? 1. Providing preoperative instructions 2. Instruction in self-examination of breasts 3. Screening for glaucoma 4. Counseling on healthy nutrition Answer: 1 Explanation: 1. The tertiary level of care focuses on stopping the disease process and returning the individual to a useful place in society. Providing preoperative instructions is a tertiary-level intervention. 2. Instructing in self-examination of the breasts is a secondary-level intervention. 3. Screening for glaucoma is a secondary-level intervention. 4. Counseling on healthy nutrition is a primary-level intervention. Page Ref: 40 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

18 ..

20) A patient is diagnosed with an ear infection and has been prescribed antibiotics. Which level of intervention has the patient received? 1. Secondary 2. Primary 3. Tertiary 4. Acute Answer: 1 Explanation: 1. The secondary level involves activities that emphasize early diagnosis and treatment of an illness to stop the pathologic process and enable the person to return to a former state of health as soon as possible. This includes receiving treatment such as antibiotic therapy for an infection. 2. Primary activities promote health and delay the occurrence of disease. 3. Tertiary interventions focus on stopping the disease process and returning the individual to society within the constraints of a disability. 4. There is no acute level of intervention. Page Ref: 40 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

19 ..

21) A middle-aged patient voices concerns about gaining 12 pounds over the past 2 years without changing any dietary habits. Which response by the nurse is most appropriate? 1. "Age-related weight gain can occur because of consistent dietary intake and less physical activity." 2. "Are you exercising?" 3. "You might be eating more than you think." 4. "You are getting older." Answer: 1 Explanation: 1. Weight gain is common in middle adulthood, usually the result of continuing to consume the same number of calories while decreasing physical activity. 2. Asking the patient about exercise fails to provide the needed information and assumes the patient is sedentary. 3. Implying the patient is overeating is judgmental and will do little to establish therapeutic rapport. 4. The patient is aware of aging, and pointing this out does little to meet the patient's obvious interest in more information. Page Ref: 28 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

20 ..

22) The nurse is assisting an adolescent female patient to strategize ways to avoid the onset of disease with aging. What should the nurse include in this plan? Select all that apply. 1. Maintain a healthy weight. 2. Avoid smoking. 3. Avoid substance abuse. 4. Schedule an annual mammogram. 5. Plan for a colonoscopy every 2 years. Answer: 1, 2, 3 Explanation: 1. Healthy behaviors that are known to promote health and wellness include eating a balanced diet, maintaining a calorie balance over time to achieve and sustain a healthy weight; and focus on consuming nutrient-dense foods and beverages. 2. Healthy behaviors that are known to promote health and wellness include eliminating smoking and use of other tobacco products such as smokeless tobacco. 3. Substance abuse is a major cause for concern in the young adult population. 4. Annual mammograms would not apply until the patient reaches the age of 40. 5. Colonoscopies would not apply until the patient reaches the age of 50. Page Ref: 28, 36 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2.2 Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 2. Recognize the health risks of individuals across the lifespan, families, and communities and the role of nursing in health promotion and maintenance.

21 ..

23) A middle-aged female patient is having a routine examination and has no significant personal or family medical history. What information concerning health-promotion behaviors should the nurse provide to this patient? 1. Have bone density evaluated. 2. Plan to have a mammogram every other year. 3. Measure blood pressure every 3 years. 4. Exercise for at least 15 minutes a day 3 days each week. Answer: 1 Explanation: 1. During the middle adult years, postmenopausal female patients may develop low bone density or osteoporosis. Bone density should be evaluated. 2. Female patients should begin having annual mammograms by age 40. 3. Blood pressure should be measured annually and more frequently if elevated. 4. Exercise recommendations are for 30 minutes 5 or more days each week. Page Ref: 28 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

22 ..

24) An older patient experiences extreme drowsiness after taking an over-the-counter cold medication at the prescribed dose. What should this information suggest to the nurse? 1. Older age is influencing the patient's response to the medication. 2. More medication was taken than was reported. 3. A reaction between the cold medication and other routine medications has occurred. 4. An allergic reaction to the cold medication occurred. Answer: 1 Explanation: 1. Older patients often experience altered responses to medications because of age-related changes in the kidneys and liver. 2. There is no evidence the patient has taken too much medication. 3. There is no information provided to indicate the patient is taking other medications. 4. Allergic reactions usually cause integumentary- or respiratory-related symptoms. Page Ref: 32 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention; | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

23 ..

25) The nurse is preparing discharge instructions for an African American patient recovering from a same-day surgical procedure. What genetic, racial, ethnic, and cultural factors affecting health and well-being should the nurse consider prior to giving discharge instructions? Select all that apply. 1. Hypertension 2. Sickle cell anemia 3. Lactose intolerance 4. Diabetes 5. Osteoporosis Answer: 1, 2, 3, 4 Explanation: 1. Certain diseases occur at a higher rate of incidence in some races and ethnic and cultural groups. Examples of illnesses that are associated with genetic makeup include hypertension among African Americans. 2. Certain diseases occur at a higher rate of incidence in some races and ethnic and cultural groups. Examples of illnesses that are associated with genetic makeup include sickle cell anemia among African Americans. 3. Certain diseases occur at a higher rate of incidence in some races and ethnic and cultural groups. Examples of illnesses that are associated with genetic makeup include lactose intolerance among African Americans. 4. Certain diseases occur at a higher rate of incidence in some races and ethnic and cultural groups. Examples of illnesses that are associated with genetic makeup include diabetes among African Americans. 5. Caucasian women of small stature and of Scandinavian heritage have a higher risk of developing osteoporosis. Page Ref: 26 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

24 ..

26) The nurse is reviewing the health history with a young adult patient. For which vaccination should the nurse assess this patient? Select all that apply. 1. Measles, mumps, rubella (MMR) 2. Hepatitis B 3. HPV 4. Influenza 5. Tetanus, diphtheria, pertussis every 10 years Answer: 2, 3, 4, 5 Explanation: 1. MMR is not recommended for a young adult. 2. Hepatitis B is recommended for a young adult. 3. HPV is recommended for a young adult. 4. Influenza vaccination is recommended annually for all adults. 5. Tetanus-diphtheria boosters are recommended every 10 years. . Page Ref: 37 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention; chronic disease management | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.2 Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 2. Recognize the health risks of individuals across the lifespan, families, and communities and the role of nursing in health promotion and maintenance.

25 ..

27) A patient is diagnosed with an acute onset of pulmonary embolism. Rank the illness behaviors that this patient may demonstrate in the commonly recognized sequence. Place the five behaviors in the correct order. Choice 1. Experiencing symptoms Choice 2. Assuming a dependent role Choice 3. Seeking medical care Choice 4. Assuming the sick role Choice 5. Recovery and rehabilitation Answer: 1, 4, 3, 2, 5 Explanation: Choice 1. Illness behaviors are the way people cope with the alterations in health and function caused by a disease. In the commonly recognized sequence of illness behaviors, the first is experiencing symptoms. Choice 2. In the commonly recognized sequence of illness behaviors, assuming a dependent role is the fourth. Choice 3. In the commonly recognized sequence of illness behaviors, seeking medical care is the third. Choice 4. In the commonly recognized sequence of illness behaviors, assuming the sick role is the second. Choice 5. In the commonly recognized sequence of illness behaviors, recovery and rehabilitation are the fifth. Page Ref: 38 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

26 ..

28) The overall mission of Healthy People 2020 is to improve the nation's health. What topic is addressed to achieve this goal? Select all that apply. 1. Access to health services 2. Nutrition and weight status 3. Reproductive health 4. Injury and violence 5. Outpatient surgery Answer: 1, 2, 3, 4 Explanation: 1. Access to health services is a health indicator used in Healthy People 2020. 2. Nutrition and weight status are health indicators used in Healthy People 2020. 3. Reproductive health is a health indicator used in Healthy People 2020. 4. Injury and violence are health indicators used in Healthy People 2020. 5. Outpatient surgery is not a health indicator in Healthy People 2020. Page Ref: 35 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.2 Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 2. Recognize the health risks of individuals across the lifespan, families, and communities and the role of nursing in health promotion and maintenance.

27 ..

29) A patient with seizures is being monitored to determine if the seizure activity was present at birth or has been slowly developing. For which classifications of diseases is this patient's seizure activity being evaluated? 1. Congenital versus chronic 2. Acute versus chronic 3. Communicable versus functional 4. Idiopathic versus iatrogenic Answer: 1 Explanation: 1. A congenital disease or disorder exists at or before birth; a chronic disease is one that requires continuing management over a long period. 2. An acute disease has a rapid onset; a chronic disease requires continuing management over a long period. 3. A communicable disease can be spread from one person to another; a functional disease affects function but does not have organic causes. 4. An idiopathic disease has an unknown cause; an iatrogenic disease is caused by medical therapy. Page Ref: 37 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; chronic disease management | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

28 ..

30) A patient with a family history of breast cancer is participating in activities to prevent illness. Which primary prevention action is the patient performing? 1. Genetic testing to determine genetic predisposition 2. Obtaining a mammogram and performing monthly breast self-examinations 3. Taking lipid-reducing agent to reduce cholesterol levels 4. Supporting breast cancer research by running in a half marathon Answer: 1 Explanation: 1. Genetic testing is primary prevention in that it determines genetically linked diseases before they develop. 2. Mammograms and self-examinations of the breasts are examples of secondary prevention. 3. Taking lipid reducing agents to treat a specific disease is secondary prevention. 4. Supporting research is tertiary level prevention that helps in stopping the disease through research efforts. Page Ref: 40 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.3 Differentiate between disease, illness, and injury, and describe illness behaviors and needs of the patient with acute, critical, and chronic illness. MNL Learning Outcome: 3. Consider the differences between disease, illness, and injury and the behaviors and needs of the patient with various levels of illness.

29 ..

31) A middle-aged female is having a routine wellness evaluation. Which statement reflects the changes that occur in middle adulthood? Select all that apply. 1. "I am embarrassed by the amount of weight I have gained each year." 2. "I have recently been put on a lipid-lowering agent for an increase in my cholesterol levels." 3. "I worry about getting breast cancer like my friend who is the same age." 4. "I have been lonely since my children all married and moved far away." 5. "I am concerned about coping with an unplanned pregnancy." Answer: 1, 2, 3, 4 Explanation: 1. This statement reflects the changes and concerns that arise in the middle adult years. 2. This statement reflects the changes and concerns that arise in the middle adult years. 3. This statement reflects the changes and concerns that arise in the middle adult years. 4. This statement reflects the changes and concerns that arise in the middle adult years. 5. While unplanned pregnancy can be a concern for perimenopausal women, this statement is more likely to come from a young adult. Page Ref: 28-29 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

30 ..

32) An older patient is experiencing confusion and lethargy after taking routine doses of medication. Which age-related change should the nurse identify that could predispose this patient to toxic drug effects? Select all that apply. 1. Changes in tissue and organ structure 2. Decrease in liver function 3. Taking several drugs at once 4. Decrease in renal function 5. Decrease in taste sensation Answer: 1, 2, 3, 4 Explanation: 1. Changes in tissue and organ structure contribute to a predisposition to toxic drug effects. 2. Reduced liver function contributes to a predisposition to toxic drug effects. 3. Taking several drugs at once contributes to a predisposition to toxic drug effects. 4. Reduced renal function contributes to a predisposition to toxic drug effects. 5. A decrease in taste sensation is an age-related change but it does not contribute to toxic drug effects. Page Ref: 32 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; chronic disease management | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.1 Define health and the health-illness continuum, and discuss factors affecting the health of individuals, families, communities, and special populations. MNL Learning Outcome: 1. Consider the impact of health, wellness, illness, and injury to patients and their families.

31 ..

33) In a healthcare provider's office, the nurse case manager approaches a patient with type 2 diabetes mellitus to review the patient-centered medical home (PCMH) approach to care. What benefits of this approach should the case manager include in this discussion? Select all that apply. 1. Prevents acute disease crises 2. Encourages preventive services 3. Eliminates health insurance billing 4. Comprehensive and coordinated care 5. Focus on all levels of illness prevention Answer: 1, 2, 4, 5 Explanation: 1. For people with chronic illnesses, the goal of the PCMH is to provide comprehensive care with a focus on preventing acute disease crises. 2. One facet of the PCMH is increased preventive services. 3. Health insurance billing is not a facet of this care delivery model. 4. PCMH is designed to provide comprehensive and coordinated patient and family care. 5. The PCMH is a primary care model that focuses on all levels of illness prevention. Page Ref: 42 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

32 ..

34) The nurse is preparing to provide disease management care to a patient with heart failure. On what should the nurse focus when caring for this patient? Select all that apply. 1. Disease process 2. Daily monitoring 3. Medication management 4. Transfer to long-term care 5. Frequency of hospitalization Answer: 1, 2, 3 Explanation: 1. In the disease management model, the focus is on education about the disease. 2. In the disease management model, the focus is on self-monitoring. 3. In the disease management model, the focus is on management. 4. Transferring to long-term care is not a focus in the disease management model. 5. The goal is to avoid hospitalization in the disease management model. Page Ref: 42 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

33 ..

35) The nurse is preparing to transition a patient with chronic obstructive pulmonary disease from a rehabilitation facility back to home. What preparations has the nurse made to support this patient's transition? Select all that apply. 1. Instructing on symptoms to report 2. Scheduling healthcare provider visits 3. Submitting facility charges to Medicare 4. Creating an evidence-based plan of care 5. Reviewing health insurance coverage plans Answer: 1, 2, 4 Explanation: 1. Interventions include an emphasis on early identification of and response to risks and symptoms to avoid adverse events. 2. Interventions include ongoing support and an emphasis on early identification of and response to risks and symptoms to avoid adverse events. 3. It is not the nurse's responsibility to bill Medicare for the patient's charges. 4. Interventions include development of an evidence-based plan of care. 5. It is not the nurse's responsibility to review health insurance coverage plans. Page Ref: 42 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

34 ..

36) The nurse notes that a patient with osteoarthritis receiving transition care has achieved the goals for this care delivery approach. What did the nurse observe to come to this conclusion? Select all that apply. 1. Safety bars installed in the bathroom 2. Oldest daughter moved out of the patient's home 3. Monthly pension from previous employer reduced 4. Adhering to exercise, pain medication, and dietary plans 5. Last hospitalization for treatment from a fall 9 months ago Answer: 1, 4, 5 Explanation: 1. The goal of transitional care is to improve the care and outcomes of chronically ill patients by streamlining plans of care, improving the ability of patients and caregivers to manage care needs, and interrupting patterns of frequent acute health crises. Installing safety bars in the bathroom is evidence that this goal has been achieved. 2. The goal of transitional care is to improve the care and outcomes of chronically ill patients by streamlining plans of care, improving the ability of patients and caregivers to manage care needs, and interrupting patterns of frequent acute health crises. The oldest daughter moving out of the home could create a care crisis if the daughter provided care to the patient. 3. The goal of transitional care is to improve the care and outcomes of chronically ill patients by streamlining plans of care, improving the ability of patients and caregivers to manage care needs, and interrupting patterns of frequent acute health crises. A reduced income could cause a crisis because it could impact resources for healthcare, medication, food, or shelter. 4. The goal of transitional care is to improve the care and outcomes of chronically ill patients by streamlining plans of care, improving the ability of patients and caregivers to manage care needs, and interrupting patterns of frequent acute health crises. Adhering to exercise, pain medication, and dietary plans indicates the ability to manage care needs. 5. The goal of transitional care is to improve the care and outcomes of chronically ill patients by streamlining plans of care, improving the ability of patients and caregivers to manage care needs, and interrupting patterns of frequent acute health crises. Being hospitalized 9 months ago indicates an interruption in the pattern of frequent acute health crises. Page Ref: 42 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care. 35 ..

36 ..

37) The nurse working in an acute care hospital is considering a position working with patients in the community. What care settings should the nurse consider before making a final decision? Select all that apply. 1. Parish nursing 2. Homeless shelters 3. Adoption agencies 4. County health department 5. Ambulatory surgical center Answer: 1, 2, 4, 5 Explanation: 1. Community-based nursing care settings include parish nursing. 2. Community-based nursing care settings include homeless shelters. 3. Community-based nursing care settings do not include adoption agencies. 4. Community-based nursing care settings include county health departments. 5. Community-based nursing care settings include ambulatory surgical centers. Page Ref: 42 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.C.4. Seek learning opportunities with patients who represent all aspects of human diversity | AACN Essentials Competencies: II.1. Apply leadership concepts, skills and decision making in the provision of high quality nursing care, healthcare team coordination and the oversight and accountability for care delivery in a variety of settings | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

37 ..

38) A patient recovering from total hip replacement surgery is being transferred to a rehabilitation facility. When discussing this facility with the patient, what should the nurse include? Select all that apply. 1. An assessment of functional abilities will be completed. 2. The patient should expect to provide all self-care. 3. A team of therapists and nurses will be working with the patient. 4. The focus will include interpersonal relationships and family support. 5. Plans will be made to transition the patient to a long-term care facility. Answer: 1, 3, 4 Explanation: 1. Assessment in a rehabilitation facility includes functional health level and selfcare abilities. 2. There is no expectation that the patient will provide all self-care. 3. Rehabilitation promotes reintegration into the patient's family and community through a team approach. 4. Many different aspects of the patient's life are addressed in the plan of care, including interpersonal relationships and family support. 5. Patients who receive care in a rehabilitation facility are not transferred to a long-term care facility. Page Ref: 43 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Knowledge and Science; Knowledge; Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

38 ..

39) The nurse is determining if a patient recovering from abdominal surgery is a candidate for home care. Which information should the nurse use to help make this decision? Select all that apply. 1. The patient needs intermittent skilled nursing care. 2. The patient prefers to use an agency that is Medicare certified. 3. The patient plans to attend the upcoming senior citizen bingo night. 4. The patient can walk to a shopping mall to do banking and purchase groceries. 5. The patient is unable to change the abdominal wound dressing because of limited upperextremity mobility. Answer: 1, 2, 5 Explanation: 1. To receive healthcare coverage for home care, the patient must need intermittent skilled nursing care. 2. To receive healthcare coverage for home care, the patient must use an agency that is Medicare certified. 3. To receive healthcare coverage for home care, the patient must be homebound and limited to leaving the home for healthcare visits or religious services. Being able to attend bingo night indicates the patient is not homebound. 4. To receive healthcare coverage for home care, the patient must be homebound and limited to leaving the home for healthcare visits or religious services. Being able to shop and bank independently means the patient is not homebound. 5. To receive healthcare coverage for home care, the patient must need intermittent skilled nursing care. Needing someone to change the wound dressing means requiring intermittent skilled nursing care. Page Ref: 44 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; healthcare systems | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

39 ..

40) The primary caregiver for a patient with Alzheimer disease receiving care in the home wants to attend a granddaughter's high school graduation in a city 50 miles from the patient's home. What should the home care nurse suggest so that the caregiver can attend this event? 1. Admit the patient to hospice. 2. Schedule respite care for the caregiver. 3. Admit the patient to an inpatient facility. 4. Transport the patient with the caregiver to the graduation. Answer: 2 Explanation: 1. Hospice care is a special component of home care, designed to provide medical, nursing, social, psychologic, and spiritual care for terminally ill patients and their families. The patient has not been diagnosed with a terminal illness. 2. Respite care provides short-term or intermittent home care, often using volunteers. These services exist primarily to give the family member or friend who is the primary caregiver some time away from care. 3. There is no medical reason for the patient to be admitted to an inpatient facility. 4. The caregiver will not be able to drive and safely care for the patient at the same time. Page Ref: 47 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.6. Describe strategies to empower patients or families in all aspects of the healthcare process | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

40 ..

41) The nurse is visiting the home of a patient recovering from an acute gastrointestinal bleed. Which action should the nurse take to limit distractions during this home visit? Select all that apply. 1. Establishing short- and long-term goals 2. Explaining the primary goal of home care 3. Exploring the patient's and family's expectations of home care 4. Asking the patient if the television could be turned off during the visit 5. Asking the patient if the visit could be conducted in the bedroom away from small children and pets Answer: 4, 5 Explanation: 1. Establishing short- and long-term goals is setting priorities with the patient. 2. Explaining the primary goal of home care is setting goals and priorities. 3. Exploring the patient's and family's expectation of home care is setting goals and priorities. 4. Asking to turn off the television is limiting a distraction. 5. Asking to conduct the visit in a room away from children and pets is limiting a distraction. Page Ref: 45 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.6. Describe strategies to empower patients or families in all aspects of the healthcare process | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

41 ..

42) After completing a home assessment, the nurse determines that safety hazards exist in a patient's bathroom. What did the nurse assess to come to this conclusion? Select all that apply. 1. Water temperature of 150°F 2. Grab bars around the toilet only 3. Scatter rug outside the shower stall 4. Smoke detector battery with a low reading 5. Electrical outlet on the wall near the shower door Answer: 1, 2, 3, 5 Explanation: 1. A water temperature of 150°F is too high. This could burn the patient. 2. Grab bars need to be within the bathtub or shower area in addition to near the commode. 3. Nonstick rugs should be used. Scatter rugs should be avoided or removed. 4. Smoke detectors are not routinely mounted near bathrooms. 5. Electrical outlets should not be near areas of water. Page Ref: 46 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Communicate potential risk factors and actual errors | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

42 ..

43) While making a home visit, the nurse learns that a patient self-administering insulin injections is placing the used needles and syringes in the family's trash can. What action should the nurse take? 1. Instruct the patient to place the needles and syringes in a separate plastic bag. 2. Nothing, because these needles and syringes are harmless to the general population. 3. Ask the patient to save all used syringes and needles after use for the nurse to dispose of. 4. Teach the patient to place all used syringes and needles into the red biohazard sharps box. Answer: 4 Explanation: 1. Used needles and syringes should not be placed in a plastic bag. They could puncture the bag and cause someone harm. 2. Doing nothing would be considered negligence on the part of the nurse. 3. The nurse is not responsible for disposing of a patient's used needles and syringes. 4. The disposal of sharp objects such as needles used for injections is a safety issue in the home. The nurse must address this with the patient, demonstrate safe disposal, and provide the necessary equipment for safe disposal. Page Ref: 46 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Communicate potential risk factors and actual errors | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

43 ..

44) During a home visit, the nurse notes that the caregiver does not apply clean gloves before removing the patient's leg wound dressings. What should the nurse do to encourage infection control practices in this home? 1. Place the box of gloves next to the sink in the bathroom. 2. Remind the caregiver to wash hands after completing wound care. 3. Place the box of gloves next to the bag used to discard soiled dressings. 4. Encourage the caregiver to touch only the edges of the soiled dressings. Answer: 3 Explanation: 1. Placing the box of gloves next to the sink in the bathroom might not be convenient enough to encourage consistent use. 2. Hand washing should occur before and after wound care. 3. If the box of gloves is next to the bag used to discard soiled dressings, the caregiver will be reminded to put on a pair of gloves before removing the dressing. 4. Touching the edges of the soiled dressing will not prevent the spread of infection. Page Ref: 46 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Communicate potential risk factors and actual errors | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2.4 Describe essential elements and goals of coordinated primary care models; the services, settings, and essential components of community-based care and home healthcare; and nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4. Recognize the various care approaches and settings for nursing care.

44 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 3 Nursing Care of the Patient with Alterations of Sleep 1) The nurse is preparing a teaching tool about rest and sleep for a group of college students. What should the nurse explain as the difference between rest and sleep? 1. Rest and sleep are the same. 2. Prolonged bed rest can be harmful. 3. Hormones are released during rest. 4. Glucose metabolism slows during sleep. Answer: 2 Explanation: 1. Rest is different than sleep because during sleep, hormones are released and short-term memories/learning are moved to long-term memories/learning. 2. Prolonged bed rest can be harmful, especially for older people. 3. Hormones are released during sleep. 4. In rest, energy is conserved and relaxation of the brain occurs where glucose is not being used as much as in strenuous thinking. Page Ref: 53 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

1 ..

2) A patient reports an inability to sleep more than 2 hours each night. In which body system should the nurse expect to assess an alteration in functioning? Select all that apply. 1. Mood 2. Satiety 3. Urine output 4. Immune system 5. Cognitive ability Answer: 1, 2, 4, 5 Explanation: 1. Changes in sleep patterns that decrease the quality and quantity of sleep can affect mood, causing irritability and depression. 2. Changes in sleep patterns that decrease the quality and quantity of sleep can affect satiety leading to overeating, obesity, and cell sensitivity to insulin. 3. Changes in sleep patterns that decrease the quality and quantity of sleep are not identified to affect renal functioning and urine output. 4. Changes in sleep patterns that decrease the quality and quantity of sleep can affect immune system functioning including a decreased ability to fight off infection. 5. Changes in sleep patterns that decrease the quality and quantity of sleep can affect cognitive functioning such as a decreased retention of new material. Page Ref: 53 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

2 ..

3) During an assessment, a patient states the inability to fall asleep at night. Which question should the nurse ask to help determine the reason for the patient's difficulty with sleep? 1. "Do you sleep with the television on?" 2. "What time do you usually go to bed?" 3. "How many hours a day do you work?" 4. "What time do you get up in the morning?" Answer: 1 Explanation: 1. Light is the most important regulator of sleep and circadian rhythms. Light is perceived by the retina and is transmitted through the retinohypothalamic tract to the suprachiasmatic nucleus (SCN) in the hypothalamus. The SCN projects into the pineal gland to either secrete or stop secreting melatonin, which is a hormone connected to sleep. When it becomes dimmer out, the pineal gland secretes melatonin, which in turn signals the body it is time to sleep. Light can affect the secretion of melatonin. This includes light from televisions which is a main reason for difficulty in falling asleep for a large portion of the population. 2. The usual time when going to bed is not identified as impacting the ability to fall asleep. 3. The number of hours worked is not identified as impacting the ability to fall asleep. 4. The time upon awakening from sleep is not identified as impacting the ability to fall asleep. Page Ref: 53 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

3 ..

4) A patient is in the intensive care area. When should the nurse expect the patient to have the best chance of falling asleep? 1. When hungry 2. When the stomach is full 3. When the body temperature increases 4. When the body temperature decreases Answer: 4 Explanation: 1. Hunger could cause a person to stay awake and hinder sleep. 2. A full stomach is not identified as an indicator for falling asleep. 3. An increase in body temperature is not identified as an indicator for falling asleep. 4. Sleep is easiest as the body temperature decreases. From a circadian rhythm perspective, decrease in body temperature occurs in the evening. Page Ref: 53 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

4 ..

5) The nurse is preparing a teaching tool on the physiologic effects of sleep for a group of new colleagues. Which information should the nurse include? Select all that apply. 1. Cortisol is decreased during the day. 2. Melatonin is increased during the day. 3. Testosterone increases during the night. 4. Blood pressure decreases during the night. 5. Growth hormone increases during the night. Answer: 3, 4, 5 Explanation: 1. Physiologically, cortisol is increased during the day. 2. Physiologically, melatonin is decreased during the day. 3. Physiologically, testosterone increases during the night. 4. Physiologically, blood pressure decreases during the night. 5. Physiologically, growth hormone increases during the night. Page Ref: 54 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

5 ..

6) A hospitalized patient is aroused from sleep every 2 hours for blood samples and vital sign assessments. Which potential health problem should the nurse add to this patient's plan of care? 1. Risk for injury 2. Fluid volume overload 3. Potential for ineffective coping 4. Ineffective self-help management Answer: 1 Explanation: 1. Patients with disrupted sleep may experience parasomnias, which are partial arousals from sleep where the person's brain is partially asleep and partially awake. For patients in the hospital setting, assessment for parasomnias is important as safety can become an issue. 2. Interrupted sleep is not identified as causing fluid overload. 3. Interrupted sleep is not identified as affecting the ability to cope. 4. Interrupted sleep is not identified as affecting self-help management. Page Ref: 55 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Quality & Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

6 ..

7) The nurse manager is identifying actions to improve the quality of sleep for patients on the care area. Which extrinsic factor should be identified as affecting sleep? 1. Noise 2. Rumination 3. Emotional state 4. Disease process Answer: 1 Explanation: 1. Extrinsic factors that affect sleep include noise, light, hunger, and room temperature. 2. Rumination is focusing on thoughts that increase anxiety and is considered a patient behavior that affects sleep. 3. Emotional state is a patient behavior that affects sleep. 4. A disease process is an intrinsic factor that affects sleep. Page Ref: 55 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

7 ..

8) A patient seeks medical attention for insomnia that occurs several times a week. Which potential health problem should the nurse identify that this patient is at risk for developing? Select all that apply. 1. Hypertension 2. Coronary artery disease 3. Cerebrovascular disease 4. Gastrointestinal disorder 5. Subclinical atherosclerotic disease Answer: 1, 2, 3, 5 Explanation: 1. Inadequate sleep due to a sleep disorder such as insomnia is correlated with hypertension. 2. Inadequate sleep due to a sleep disorder such as insomnia is correlated with coronary artery disease. 3. Inadequate sleep due to a sleep disorder such as insomnia is correlated with cerebrovascular disease. 4. Inadequate sleep is not identified as contributing to the development of gastrointestinal disorders. 5. Inadequate sleep due to a sleep disorder such as insomnia is correlated with subclinical atherosclerotic disease. Page Ref: 55 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

8 ..

9) The nurse notes that a patient has significant daytime sleepiness. Which medication should the nurse identify could be causing this patient's symptom? Select all that apply. 1. Levodopa 2. Tiotopium 3. Metoprolol 4. Procainamide 5. Amitriptyline Answer: 1, 2, 4, 5 Explanation: 1. Levodopa is identified as causing daytime sleepiness. 2. Tiotopium is identified as causing daytime sleepiness. 3. Metoprolol is identified as increasing the number of awakenings and total time awake at night with the potential to provoke nightmares. 4. Procainamide is identified as causing daytime sleepiness. 5. Amitriptyline is identified as causing daytime sleepiness. Page Ref: 56 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

9 ..

10) The nurse is planning care for a patient with chronic obstructive pulmonary disease (COPD). Which should the nurse consider to ensure this patient receives adequate sleep? 1. Wheezing will increase the amount of sleep. 2. Bronchodilators will enhance the onset of sleep. 3. The disease process and medications to treat will affect sleep. 4. Chronic coughing will have minimal effect on quality of sleep. Answer: 3 Explanation: 1. Wheezing during the night will either awaken the patient or cause an arousal or sleep stage change. 2. Bronchodilators can delay the onset of sleep. 3. Any respiratory disorder has the potential to affect sleep. Medications to treat symptoms at nighttime can also disrupt sleep. 4. Chronic coughing during the night will either awaken the patient or cause an arousal or sleep state change. Page Ref: 56 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.1 Describe the physiology of sleep, normal sleep patterns, and factors affecting sleep. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

10 ..

11) A college student is having difficulty staying awake during classes and is doing poorly in school. What should the nurse recommend to improve this patient's quality of sleep? Select all that apply. 1. Exercise daily. 2. Limit caffeine in the afternoon. 3. Have a consistent wakeup time. 4. Keep the bedroom cool, dark, and quiet. 5. Turn the volume of the television to low. Answer: 1, 2, 3, 4 Explanation: 1. A daytime action for good sleep hygiene includes daily exercise. 2. A daytime action for good sleep hygiene includes limiting caffeine in the afternoon. 3. A daytime action for good sleep hygiene includes having a consistent wakeup time. 4. A nighttime action for good sleep hygiene includes keeping the bedroom cool, dark, and quiet. 5. A nighttime action for good sleep hygiene includes not using the television or other electronics in the bedroom. Page Ref: 57 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.2 Summarize topics that nurses teach to promote healthy sleep across the lifespan. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

11 ..

12) The nurse is caring for patients during the night shift. Which action should the nurse take to prevent interrupting the patients' sleep? 1. Keep the room doors open. 2. Turn on the overhead light. 3. Use a flashlight in the rooms. 4. Keep the curtains open between patients. Answer: 3 Explanation: 1. Room doors should be kept closed to reduce environmental noise and light from interrupting sleep. 2. The overhead light should not be turned on since this could wake up the patients. 3. Flashlights should be used in the patient rooms since this will prevent wakening the patients. 4. Curtains should be pulled between the patients. Page Ref: 57 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.2 Summarize topics that nurses teach to promote healthy sleep across the lifespan. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

12 ..

13) A patient reports having difficulty sleeping since being discharged from the hospital. Which should the nurse recommend to this patient to improve sleep? 1. Take brief naps throughout the day. 2. Watch a movie on the television when going to bed. 3. Limit the amount of physical activity obtained during the day. 4. Open the curtains immediately upon waking up in the morning. Answer: 4 Explanation: 1. Napping during the day should be discouraged since this will interrupt nighttime sleep. 2. The television should not be on during the night. 3. Daily exercise helps the body build up the "pressure" for sleep. 4. The body needs to be trained for good sleep. This starts at the time of awakening with bright light exposure. The bright light stops the secretion of melatonin. Page Ref: 56-57 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.2 Summarize topics that nurses teach to promote healthy sleep across the lifespan. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

13 ..

14) A patient reports having problems sleeping over the last few weeks. What should the nurse do to support the assessment process? 1. Encourage the patient to wait it out. 2. Recommend the patient keep a sleep diary. 3. Ask family members to describe the patient's sleep. 4. Suggest the patient videotape the hours during sleep. Answer: 2 Explanation: 1. Waiting it out will not help provide any additional assessment information. 2. Having the patient keep a sleep diary for a couple of days provides good information for the assessment process. 3. Family members should not be asked to help collect data about the patient's sleep behaviors. 4. Suggesting the patient videotape the hours during sleep is an unrealistic expectation. Page Ref: 57-58 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3 Outline the components of the assessment of sleep including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

14 ..

15) A patient with several chronic health problems reports difficulty sleeping through the night. What should the nurse include when assessing this patient? Select all that apply. 1. Weight 2. Neck size 3. Oropharynx 4. Blood pressure 5. Body mass index Answer: 1, 2, 3, 5 Explanation: 1. The majority of information for sleep disorders is found during the interview phase of an assessment as opposed to the physical examination; however, weight should be measured. 2. The majority of information for sleep disorders is found during the interview phase of an assessment as opposed to the physical examination; however, neck size should be measured. 3. The majority of information for sleep disorders is found during the interview phase of an assessment as opposed to the physical examination; however, the oropharynx should be assessed for crowding or a small air space at the back of the throat. 4. The majority of information for sleep disorders is found during the interview phase of an assessment as opposed to the physical examination; however, blood pressure is not a parameter within the sleep assessment. 5. The majority of information for sleep disorders is found during the interview phase of an assessment as opposed to the physical examination; however, body mass index should be assessed. Page Ref: 57 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.3 Outline the components of the assessment of sleep including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

15 ..

16) A patient is experiencing extreme daytime sleepiness but is unable to sleep during the night. For which diagnostic test should the nurse prepare teaching for this patient? 1. Polysomnography 2. CT scan of the brain 3. Electroencephalogram 4. Nerve conduction studies Answer: 1 Explanation: 1. Polysomnography is a multichannel overnight study to assess sleep quality, type, and respiratory issues along with neurological issues. 2. A CT scan of the brain is not used to diagnose a sleep disorder. 3. An electroencephalogram is not used to diagnose a sleep disorder. 4. Nerve conduction studies are not used to diagnose a sleep disorder. Page Ref: 58 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 3.3 Outline the components of the assessment of sleep including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

16 ..

17) A patient experiencing menopause is concerned about the inability to sleep through the night. For which potential health problem should the nurse assess this patient? 1. Osteoporosis 2. Heart disease 3. Obstructive sleep apnea 4. Chronic obstructive pulmonary disease Answer: 3 Explanation: 1. Osteoporosis is not identified as causing difficulty with sleep. 2. There is no indication that the patient has heart disease. 3. Patients in menopause have a risk for obstructive sleep apnea due to changes in progesterone and fat redistribution. 4. There is no indication that the patient has chronic obstructive pulmonary disease. Page Ref: 59 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4 Differentiate considerations for assessing the sleep of older adults, veterans, and individuals in the LGBTQI population. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

17 ..

18) The spouse of a Middle East war veteran is concerned because the patient screams often during sleep and wakes up the entire household. What should the nurse consider as the reason for the patient's behavior during sleep? 1. Alcoholism 2. Depression 3. Posttraumatic stress disorder 4. Adverse medication reaction Answer: 3 Explanation: 1. Screaming during sleep is not associated with alcoholism. 2. Screaming during sleep is not associated with depression. 3. Changes in sleep patterns in veterans will depend on any injury or disease caused by being in service. Nightmares or insomnia could indicate posttraumatic stress disorder. 4. Screaming during sleep is not associated with adverse medication reactions. Page Ref: 59 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Stress Management Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.4 Differentiate considerations for assessing the sleep of older adults, veterans, and individuals in the LGBTQI population. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

18 ..

19) The nurse suspects that a patient is experiencing difficulty sleeping. Which assessment finding caused the nurse to make this clinical determination? Select all that apply. 1. Irritable 2. Slow reflexes 3. Heart rate 108 bpm 4. Inability to concentrate 5. Blood pressure 110/68 mmHg Answer: 1, 2, 3, 4 Explanation: 1. A sleep deficit can affect physiologic, emotional, and cognitive functioning. Irritability can occur. 2. A sleep deficit can affect physiologic, emotional, and cognitive functioning. Slow reflexes can occur. 3. A sleep deficit can affect physiologic, emotional, and cognitive functioning. An increase in heart rate can occur. 4. A sleep deficit can affect physiologic, emotional, and cognitive functioning. An inability to concentrate can occur. 5. A sleep deficit can affect physiologic, emotional, and cognitive functioning. Low blood pressure is not associated with a sleep deficit. Page Ref: 59 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.5 Describe the pathophysiology and manifestations of sleep deprivation, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

19 ..

20) A patient being treated for a sleep disorder reports no change in the ability to sleep through the night. What should the nurse assess first with this patient? 1. Vital signs 2. Amount of stress 3. Home environment 4. Adherence with the prescribed treatment Answer: 4 Explanation: 1. There is no reason for vital signs to be assessed first. 2. Assessing stress level may be indicated; however, the patient's adherence to the prescribed treatment should be assessed first. 3. The home environment may need to be assessed; however, the patient's adherence to the prescribed treatment should be assessed first. 4. Adherence to treatment is a major concern for almost all of the sleep disorders. The patient's adherence to the prescribed treatment should be assessed first. Page Ref: 59 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.5 Describe the pathophysiology and manifestations of sleep deprivation, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

20 ..

21) The nurse is assessing a patient with insomnia. Which additional health problem should the nurse include in the assessment? Select all that apply. 1. Anxiety 2. Gastritis 3. Headaches 4. Depression 5. Osteoarthritis Answer: 1, 3, 4 Explanation: 1. Insomnia has been shown to be a risk factor for the development of anxiety. 2. Insomnia has been shown to be a risk factor for the development of anxiety, headaches, and depression. Gastritis is not linked to insomnia. 3. Insomnia has been shown to be a risk factor for the development of headaches. 4. Insomnia has been shown to be a risk factor for the development of depression. 5. Insomnia has been shown to be a risk factor for the development of anxiety, headaches, and depression. Osteoarthritis is not linked to insomnia Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

21 ..

22) The nurse is reviewing the process of insomnia with a group of colleagues. Which should the nurse identify as a predisposing factor for the health problem? 1. Worry 2. Life stress 3. Loss of a job 4. Poor coping skills Answer: 1 Explanation: 1. When studying the pathophysiology of insomnia, worry is identified as a predisposing factor for the health problem. 2. When studying the pathophysiology of insomnia, life stress is identified as a precipitating factor for the health problem. 3. When studying the pathophysiology of insomnia, loss of a job is identified as a precipitating factor for the health problem. 4. When studying the pathophysiology of insomnia, poor coping skills are identified as perpetuating factors for the health problem. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.6. Use information and communication technologies in preventive care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

22 ..

23) A patient seeks medical attention for insomnia that has been occurring over the last several months. For which reason would actigraphy be used for this patient? 1. Confirm the diagnosis of insomnia. 2. Identify the degree of difficulty sleeping. 3. Evaluate the effectiveness of medication. 4. Determine the best medication to prescribe. Answer: 2 Explanation: 1. At times, actigraphy will be used to assess the patient's sleep patterns over a period of time. The results of the actigraphy are not used to confirm the diagnosis of insomnia. 2. At times, actigraphy will be used to assess the patient's sleep patterns over a period of time. The results of the actigraphy are used to elucidate further the degree of difficulty sleeping. 3. At times, actigraphy will be used to assess the patient's sleep patterns over a period of time. The results of the actigraphy are not used to evaluate the effectiveness of medication. 4. At times, actigraphy will be used to assess the patient's sleep patterns over a period of time. The results of the actigraphy are not used to determine the best medication to prescribe. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

23 ..

24) A patient with insomnia asks for medication "to sleep." Which should the nurse explain about using this type of medication? 1. It does not cure the problem. 2. It is the best treatment approach for the problem. 3. It will eliminate the problem if used consistently. 4. It will provide the best rest with minimal side effects. Answer: 1 Explanation: 1. The key issue with medication use in insomnia is once the medication is stopped the insomnia will still be present. 2. Medication for the treatment of insomnia should be used only short term while other proven therapies, such as cognitive-behavioral therapy, are implemented to help resolve the underlying issues of insomnia. 3. Medication used consistently for sleep will not eliminate the problem. 4. A number of the medications used to treat insomnia have significant side effects. Even the medications with FDA approval for insomnia have serious reported side effects. Page Ref: 60 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

24 ..

25) A patient has a motor vehicle crash but does not remember getting into the car to drive. Which question should the nurse ask when assessing this patient? 1. "What medication are you taking?" 2. "What health problems do you have?" 3. "What is the last thing you remember?" 4. "Where do you think you were going?" Answer: 1 Explanation: 1. Sleep driving has occurred especially when used with other central nervous system depressants. The patient's list of medications needs to be assessed. 2. There is no reason to assess the patient's health problems. 3. Asking the last thing the patient remembers will not help identify the reason for the sleep driving. 4. Asking where the patient was going will not help identify the reason for the sleep driving. Page Ref: 61 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

25 ..

26) A patient is given zolpidem (Ambien) at bedtime. Which action should the nurse take when the patient needs to void in the middle of the night? 1. Provide a bedpan. 2. Insert a urinary catheter. 3. Provide a bedside commode. 4. Ambulate the patient to the bathroom. Answer: 4 Explanation: 1. There is no reason for the patient to be given a bedpan. 2. There is no reason for the patient to have a urinary catheter inserted. 3. There is no reason for the patient to use a bedside commode. 4. After providing sleeping medication, a safe environment should be provided by monitoring the patient's ambulation after taking the drug. Page Ref: 61 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

26 ..

27) A patient who has been taking zaleplon (Sonata) for several months asks for a prescription refill before the appropriate length of time. Which action should the nurse take? 1. Assess about frequency of use. 2. Ask the healthcare provider to renew the prescription. 3. Suggest the patient use alternative approaches to sleep. 4. Explain that the patient will have to wait until the prescription can be refilled. Answer: 1 Explanation: 1. Patients taking a sleeping agent such as zaleplon (Sonata) should be monitored for tolerance, abuse, and dependence. The nurse needs to learn how frequent the medication is being used and the number of doses being taken each time. 2. Additional information would be required before asking the healthcare provider to renew the prescription. 3. It is beyond the nurse's scope of practice to recommend another approach to sleep. 4. The patient may need to wait to have the prescription refilled; however, an assessment of tolerance, abuse, and dependence should be completed first. Page Ref: 61 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 3. Perform assessment for patients with alterations of sleep.

27 ..

28) The nurse instructs a patient about the prescribed medication zolpidem (Ambien). Which patient statement indicates that teaching was effective? 1. "This medication causes no side effects." 2. "I should report any confusion or hallucinations." 3. "I can take this medication with my evening cocktail." 4. "I can take this medication any time before going to bed." Answer: 2 Explanation: 1. Zolpidem (Ambien) can cause daytime drowsiness, amnesia, confusion, sleep walking, and hallucinations. 2. Zolpidem (Ambien) can cause daytime drowsiness, amnesia, confusion, sleep walking, and hallucinations. 3. Zolpidem (Ambien) should not be taken with any alcohol. 4. The patient should be advised to get into bed immediately after taking zolpidem (Ambien). Page Ref: 61 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 3.6 Describe the pathophysiology and manifestations of insomnia, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

28 ..

29) The nurse is preparing a teaching tool about obstructive sleep apnea. Which information about risk factors should the nurse include? Select all that apply. 1. Obesity 2. Male gender 3. Alcohol intake 4. Large neck size 5. Small oropharynx Answer: 1, 2, 4, 5 Explanation: 1. Obesity is a risk factor for obstructive sleep apnea. 2. Male gender is a risk factor for obstructive sleep apnea. 3. Alcohol intake is not a risk factor for obstructive sleep apnea. 4. Large neck size is a risk factor for obstructive sleep apnea. 5. Small oropharynx is a risk factor for obstructive sleep apnea. Page Ref: 62 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

29 ..

30) The nurse suspects that a patient has undiagnosed obstructive sleep apnea (OSA). What observation caused the nurse to come to this conclusion about the patient? Select all that apply. 1. Poor coordination 2. Morning headache 3. Daytime sleepiness 4. Snoring while asleep 5. Waking up gasping for air Answer: 2, 3, 4, 5 Explanation: 1. Poor coordination is not identified as a manifestation of OSA. 2. A morning headache is a daytime symptom of OSA. 3. Daytime sleepiness is a daytime symptom of OSA. 4. Snoring is a nighttime symptom of OSA. 5. Gasping for air is a nighttime symptom of OSA. Page Ref: 62 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

30 ..

31) An overweight patient is diagnosed with obstructive sleep apnea (OSA). What teaching material should the nurse consider first for this patient? 1. Oral device 2. Neurostimulator 3. Weight management 4. Positive airway pressure Answer: 3 Explanation: 1. An oral device is an option to help with OSA; however, this is not the first approach to be used. 2. A neurostimulator is an option to help with OSA; however, this is not the first approach to be used. 3. If the patient is overweight, the best treatment for OSA is weight loss. The patient does not need to be at ideal weight, but even a small percentage of weight loss can be effective. 4. Positive airway pressure is an option to help with OSA; however, this is not the first approach to be used Page Ref: 62 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

31 ..

32) A patient with obstructive sleep apnea (OSA) asks why a mouth retainer is prescribed since there are no problems with the teeth. Which response should the nurse make to the patient? 1. "Obstructive sleep apnea is caused by misaligned teeth." 2. "The mouth retainer will keep your jaw in alignment while sleeping." 3. "The mouth retainer decreases the diameter of the back of the throat." 4. "The mouth retainer will help you keep your mouth closed while sleeping." Answer: 2 Explanation: 1. OSA is not caused by misaligned teeth. 2. Oral devices help bring forward the jaw and tongue which increases the diameter of the posterior oropharynx. 3. Oral devices increase the diameter of the posterior oropharynx. 4. Oral devices are not used to keep the mouth closed during sleep. Page Ref: 62 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

32 ..

33) A patient is being considered for a hypoglossal nerve stimulator. Which patient criteria was most likely used for this treatment to be identified? 1. Is obese 2. Sleeps with three pillows 3. Takes medication for hypertension 4. Has moderate to severe obstructive sleep apnea (OSA) Answer: 4 Explanation: 1. A hypoglossal nerve stimulator is not indicated for obesity. 2. A hypoglossal nerve stimulator is not indicated for orthopnea. 3. A hypoglossal nerve stimulator is not used to treat hypertension. 4. A hypoglossal nerve stimulator stimulates the hypoglossal nerve to maintain upper airway patency during sleep. This is used for moderate to severe OSA in adults. Page Ref: 63 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

33 ..

34) The nurse is preparing a teaching tool for patients who are prescribed continuous positive airway pressure (CPAP) as treatment for obstructive sleep apnea (OSA). Which potential adverse effect from the use of the device should the nurse include? Select all that apply. 1. Dry nose 2. Neck pain 3. Air swallowing 4. Facial excoriations 5. Esophageal spasms Answer: 1, 3, 4 Explanation: 1. A dry nose is an issue associated with the use of CPAP. 2. Neck pain is not an issue associated with the use of CPAP. 3. Air swallowing is an issue associated with the use of CPAP. 4. Facial excoriations are an issue associated with the use of CPAP. 5. Esophageal spasms are not an issue associated with the use of CPAP. Page Ref: 63 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

34 ..

35) The nurse is asked to explain central sleep apnea (CSA). In which way should the nurse respond? Select all that apply. 1. "It is seen with substance abuse." 2. "It can be caused by medication." 3. "It is associated with medical disorder." 4. "It occurs with Cheyne-Stokes breathing." 5. "It is another term for the obstructive form." Answer: 1, 2, 3, 4 Explanation: 1. CSA is a consolidation of different types of apnea including being caused by substance abuse. 2. CSA is a consolidation of different types of apnea including being caused by medication. 3. CSA is a consolidation of different types of apnea including being caused by a medical disorder. 4. CSA is a consolidation of different types of apnea including Cheyne-Stokes breathing. 5. CSA is not another term for obstructive sleep apnea (OSA). Page Ref: 63 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

35 ..

36) A patient is being evaluated for central sleep apnea (CSA). What should the nurse expect to assess in this patient? Select all that apply. 1. Daytime fatigue 2. Daytime sleepiness 3. Nighttime pauses in breathing 4. Nighttime drop in blood pressure 5. Daytime increase in blood glucose Answer: 1, 2, 3 Explanation: 1. All patients with CSA will experience tiredness during the day. 2. All patients with CSA will experience daytime sleepiness. 3. Symptoms during sleep will include pauses in breathing without any effort or waxing/waning respirations. 4. CSA does not cause a nighttime drop in blood pressure. 5. CSA does not cause a daytime increase in blood glucose. Page Ref: 64 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

36 ..

37) The nurse is planning care for a patient with central sleep apnea (CSA). For which treatment should the nurse plan interventions? Select all that apply. 1. Surgery 2. Medication therapy 3. Supplemental oxygen 4. Noninvasive ventilation 5. Positive airway pressure Answer: 3, 4, 5 Explanation: 1. There is not a surgical procedure for CSA. 2. There are no medications for treating CSA. 3. Treatment for CSA in some cases includes supplemental oxygen. 4. Treatment for CSA in some cases includes noninvasive ventilation. 5. Treatment for CSA involves different types of positive airway pressure at night. Page Ref: 64 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.7 Describe the pathophysiology and manifestations of sleep-disordered breathing, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

37 ..

38) The nurse is reviewing data collected during a patient assessment. Which information should the nurse identify that supports the patient's diagnosis of restless leg syndrome (RLS)? 1. Low iron level 2. Low potassium level 3. Elevated platelet level 4. Elevated hemoglobin level Answer: 1 Explanation: 1. The pathophysiology of RLS relates to dopamine levels in the brain. The dopamine is needed for effective neuromuscular action and response. In the brain, one of the limiting factors for producing dopamine is iron. Patients with low iron stores are more likely to have RLS than those who do not. 2. RLS is not caused by a low potassium level. 3. RLS is not caused by an elevated platelet level. 4. RLS is not caused by an elevated hemoglobin level. Page Ref: 64 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3.8 Describe the pathophysiology and manifestations of restless legs syndrome, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine normal physiology, pathophysiology, risk factors, and clinical manifestations for patients with alterations of sleep.

38 ..

39) The nurse is preparing a teaching tool about restless leg syndrome (RLS). Which risk factor should the nurse include about this health problem? Select all that apply. 1. Renal failure 2. Heart disease 3. Family history 4. Gastroenteritis 5. Parkinson disease Answer: 1, 3, 5 Explanation: 1. A disease process that decreases iron stores places a patient at risk for RLS including renal failure. 2. Heart disease is not a risk factor for RLS. 3. A family history of RLS is a risk factor for the health problem. 4. Gastroenteritis is not a risk factor for RLS. 5. Any neuromuscular disease including Parkinson disease places a patient at a higher risk for RLS. Page Ref: 64 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 3.8 Describe the pathophysiology and manifestations of restless legs syndrome, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing care for patients with alterations of sleep.

39 ..

40) A patient seeks medical treatment for restless leg syndrome (RLS). Which medication should the nurse expect to be prescribed first for this patient? 1. Opioids 2. Dopamine 3. Gabapentin 4. Iron supplement Answer: 3 Explanation: 1. Treatment for RLS begins with gabapentin. If that is ineffective, dopamine is used and occasionally opioids. 2. Treatment for RLS begins with gabapentin. If that is ineffective, dopamine is used and occasionally opioids. 3. Treatment for RLS begins with gabapentin. If that is ineffective, dopamine is used and occasionally opioids. 4. Final treatment for RLS is the use of iron supplements but only if the patient has low iron stores. Page Ref: 64 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3.8 Describe the pathophysiology and manifestations of restless legs syndrome, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with alterations of sleep.

40 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 4 Nursing Care of Patients Having Surgery 1) A patient believes that scheduled surgery is minor since it will be done as an outpatient. How should the nurse respond to this patient? 1. "Every surgical procedure is serious, and I will make sure you have information to have a successful recovery." 2. "You are right." 3. "If it were more serious, you would be admitted to the hospital." 4. "Your insurance plan does not cover inpatient surgical procedures. That's why your surgery is being done as an outpatient." Answer: 1 Explanation: 1. The complexity of the surgery and recovery and the expected level of care needed on completion of the surgery are the major differences between inpatient and outpatient surgical procedures. The outpatient surgical patient and family must cope with the additional stress of needing to learn a great deal of information in a short span of time. The nurse should explain that every surgical procedure is serious and that the patient will be given information to have a successful recovery. 2. The nurse should not agree with the patient about outpatient surgery being minor. 3. The nurse does not know if the patient needs to be admitted to the hospital. 4. The nurse does not have enough information about the patient's insurance coverage to make the statement about the patient having surgery as an outpatient. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

1 ..

2) A patient scheduled for outpatient surgery asks why admission to the hospital is not required. What should the nurse explain as an advantage of having outpatient surgery? 1. Reduced risk of healthcare-associated infections. 2. Ability to use home care for postoperative care in the home. 3. Reduced use of postoperative medications. 4. Inadequate staffing on the surgical care areas. Answer: 1 Explanation: 1. Advantages to outpatient surgery include a reduced risk of healthcareassociated infections. 2. The patient may or may not have home care for postoperative care in the home. 3. There is no evidence to suggest that patients who have outpatient surgery use fewer postoperative medications. 4. Saying that staffing on the surgical care areas is inadequate would be inappropriate. Page Ref: 75 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

2 ..

3) The nurse is preparing to discharge a patient after having outpatient surgery. Which criteria should the nurse use to determine whether the patient is eligible to be discharged? Select all that apply. 1. Stable vital signs 2. No nausea or dizziness 3. Pain controlled 4. Adequate urine output 5. Patient's expressed readiness to go home Answer: 1, 2, 3, 4 Explanation: 1. Following outpatient surgery, the patient will be discharged after meeting the institution's criteria, which typically include tolerance of fluids or food, stable vital signs, absence of nausea or dizziness, pain control, adequate urine output, as well as patient being oriented and demonstrating understanding of postoperative instructions. 2. Following outpatient surgery, the patient will be discharged after meeting the institution's criteria, which typically include tolerance of fluids or food, stable vital signs, absence of nausea or dizziness, pain control, adequate urine output, as well as patient being oriented and demonstrating understanding of postoperative instructions. 3. Following outpatient surgery, the patient will be discharged after meeting the institution's criteria, which typically include tolerance of fluids or food, stable vital signs, absence of nausea or dizziness, pain control, adequate urine output, as well as patient being oriented and demonstrating understanding of postoperative instructions. 4. Following outpatient surgery, the patient will be discharged after meeting the institution's criteria, which typically include tolerance of fluids or food, stable vital signs, absence of nausea or dizziness, pain control, adequate urine output, as well as patient being oriented and demonstrating understanding of postoperative instructions. 5. The patient's expressing readiness to go home is not a criterion that would make him or her eligible for discharge after outpatient surgery. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.10. Facilitate patient-centered transitions of care, including discharge planning and ensuring the caregiver's knowledge of care requirements to promote safe care | NLN Competencies: Context and Environment; PracticeKnow-How; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

3 ..

4) The nurse in the same-day surgical care area is preparing a patient for surgery. What should the nurse do to ensure that this patient has a successful recovery from the surgery? 1. Provide teaching and additional resources to help the patient when at home. 2. Measure intake and output. 3. Assess vital signs. 4. Limit pain control measures since the patient will need to ambulate when leaving after the surgery. Answer: 1 Explanation: 1. Because the postoperative phase does not end until recovery is complete, the nurse's role as educator is vital as the patient nears discharge. As the patient prepares to recuperate at home, the nurse provides information and support as needed for self-care. Written guidelines, directions, and information should accompany all aspects of teaching. Opportunities for patient and family teaching are often brief, necessitating an organized, coordinated effort. 2. The nurse may or may not need to measure the patient's intake and output. 3. The nurse will assess all surgical patients' vital signs. 4. The nurse should ensure the patient's pain is controlled and not limit pain medication. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Learn continuously, learn cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

4 ..

5) A patient recovering from surgery, experiences a deep vein thrombosis (DVT). Which preoperative exercise should the nurse identify as being ineffective for this patient? 1. Leg exercises 2. Deep breathing and coughing 3. Use of incentive spirometry 4. Splinting when coughing Answer: 1 Explanation: 1. Preoperative patient teaching includes leg exercises in order to reduce the onset of the complication deep vein thrombosis. The development of a DVT indicates teaching was ineffective. 2. Deep breathing and coughing are helpful to prevent complications of pneumonia and atelectasis. 3. Use of incentive spirometry is helpful to prevent complications of pneumonia and atelectasis. 4. Splinting when coughing is taught so that thoracic and abdominal incisions are maintained and protected from an increase in intra-abdominal pressure that occurs when coughing. Page Ref: 81 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

5 ..

6) The nurse is assessing a patient who has returned to the care area after surgery. What should the nurse do to ensure the patient receives appropriate care? 1. Check the physician's orders to see if preoperative orders have been reordered. 2. Schedule the patient for vital signs assessments every four hours. 3. Orient the patient to person, place, and time. 4. Assess the patient's mental status. Answer: 1 Explanation: 1. The medical record needs to be checked to ensure that all orders written before surgery have been reordered after surgery, since the patient's condition has changed. 2. Even though vital signs should be assessed according to hospital policy, the frequency of a postoperative patient's vital signs assessment will be more frequent than every four hours. 3. Orienting the patient to person, place, and time, is an activity of the PACU nurse. 4. Assessing the patient's mental status is an activity of the PACU nurse. Page Ref: 95 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

6 ..

7) After providing a preoperative sedative, the nurse notes that the surgical consent form has not been signed by the patient. What should the nurse do? 1. Contact the surgeon. 2. Ask the patient to sign the consent form. 3. Send the patient for surgery with an unsigned consent form. 4. Phone the operating room suite to notify the nurse that the patient has not signed the consent form. Answer: 1 Explanation: 1. The patient should be aware and alert before signing the consent form. The nurse should contact the surgeon in the event the patient receives preoperative sedative medication and has not yet signed the consent for surgery form. The surgeon who performs a procedure is responsible for obtaining the patient's consent for care. 2. The nurse should not ask the patient to sign the consent form if the patient is under the influence of a sedative. 3. The nurse should not send the patient for surgery with an unsigned consent form. 4. The nurse should not phone the operating room suite to notify the nurse that the patient has not signed the consent form. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.10. Engage patients or designated surrogates in active partnerships that promote health, safety and well-being, and self-care management | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality & Safety; Practice-Know-How; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

7 ..

8) A patient being prepared for surgery has been diagnosed with dehydration. Which laboratory values support the diagnosis for this patient? 1. Hemoglobin and hematocrit 2. Glucose 3. White blood cell count 4. Platelet count Answer: 1 Explanation: 1. An increase in hemoglobin and hematocrit levels would indicate dehydration. 2. An alteration in glucose level could indicate impaired glucose metabolism or inadequate glucose level. 3. An alteration in white blood cell count could indicate an infection or immune deficiencies. 4. An alteration in platelet count could indicate a malignancy or clotting deficiency disorder. Page Ref: 82 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Read and interpret data | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

8 ..

9) A patient diagnosed with emphysema is being prepared for surgery. What laboratory value should the nurse review to obtain information about the patient's respiratory status? 1. Carbon dioxide 2. White blood cell count 3. Serum creatinine 4. Blood urea nitrogen Answer: 1 Explanation: 1. The carbon dioxide level will be elevated in a patient with emphysema. This is the laboratory value that would provide information about the patient's respiratory status. 2. The white blood cell count would provide information regarding an infection or immune deficiency. 3. The serum creatinine level provides information about the patient's renal status. 4. The blood urea nitrogen level also provides information about the patient's renal status. Page Ref: 82 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Read and interpret data | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

9 ..

10) An older adult patient being prepared for surgery is scheduled for an electrocardiogram. What should the nurse explain to the patient regarding the purpose of this test? 1. It is routine for all patients having general anesthesia. 2. It is used to diagnose preexisting cardiac disease. 3. It is one way to validate laboratory values 4. It is a predictor of surgical procedure success. Answer: 1 Explanation: 1. An electrocardiogram (ECG) is ordered routinely for patients undergoing general anesthesia when they are over 40 years of age or have cardiovascular disease. 2. The electrocardiogram might detect preexisting cardiac disease but will not diagnose disease. 3. The electrocardiogram will not validate laboratory values. 4. The electrocardiogram is not used to predict the success of surgical procedures. Page Ref: 82 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Read and interpret data | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

10 ..

11) An older patient, being prepared for surgery, has a low glomerular filtration rate. Which aspect of the patient's care should the nurse realize this finding will impact? 1. Medication dosages 2. Postoperative activity level 3. Intraoperative bleeding 4. Oxygenation status Answer: 1 Explanation: 1. A patient susceptible to renal insufficiency is at risk for fluid volume overload in the perioperative period and for accumulation of metabolic by-products and medications dependent on renal clearance. When this risk is known, renal function testing may be performed preoperatively. It is evaluated on the basis of glomerular filtration rate (GFR), which is estimated by using serum creatinine (reported as the eGFR) or by measuring urinary creatinine. Creatinine is a stable product of muscle mass; it is filtered by the kidneys or secreted by the kidney tubules. In kidney failure, serum creatinine rises and the GFR is low. The best indicator of GFR is the creatinine clearance, a comparison of both serum and urinary creatinine levels. Medication dosages will need to be adjusted for the older patient with a low glomerular filtration rate. 2. The glomerular filtration rate will not impact the patient's postoperative activity level. 3. The glomerular filtration rate will not impact the amount of intraoperative bleeding. 4. The glomerular filtration rate will not impact the patient's oxygenation status. Page Ref: 82 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.19. Manage the interaction of multiple functional problems affecting patients across the lifespan, including common geriatric syndromes | NLN Competencies: Context and Environment; Practice-Know-How; Read and interpret data | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

11 ..

12) A patient is scheduled for total hip replacement surgery. What medication should the nurse provide to the patient prior to the surgical procedure? 1. Antibiotic 2. Antacid 3. Antiemetic 4. Anticholinergic Answer: 1 Explanation: 1. Antibiotics are given preoperatively to orthopedic patients to prevent postoperative infections. 2. Antacids increase the gastric pH and reduce the volume of gastric fluid. 3. Antiemetics enhance gastric emptying. 4. Anticholinergics reduce oral and respiratory secretions to decrease the risk of aspiration and vomiting. Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

12 ..

13) A patient received lorazepam (Ativan) as preoperative medication. What should the nurse assess when caring for this patient? 1. Respiratory depression 2. Nausea and vomiting 3. Confusion 4. Rash Answer: 1 Explanation: 1. The patient who received lorazepam (Ativan) should be monitored for respiratory depression, hypotension, lack of coordination, and drowsiness. 2. Nausea and vomiting is not associated with the use of lorazepam (Ativan). 3. Confusion is not associated with the use of lorazepam (Ativan). 4. Rash is not associated with the use of lorazepam (Ativan). Page Ref: 84 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

13 ..

14) A patient with a history of sleep apnea is experiencing difficulty maintaining an airway during conscious sedation. What should the nurse do to assist this patient? 1. Prepare to administer a reversal agent. 2. Begin artificial ventilations. 3. Measure oxygen saturation. 4. Apply prescribed oxygen via face mask. Answer: 1 Explanation: 1. Patients with a history of sleep apnea may have difficulty with conscious sedation. The nurse should prepare to administer a reversal agent to the patient. 2. The patient may or may not need artificial ventilations at this time. 3. The nurse should have been measuring the patient's oxygen saturation throughout the procedure. 4. The patient is having difficulty maintaining an airway so applying oxygen via face mask may not be appropriate. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

14 ..

15) The nurse is caring for a patient recovering from surgery conducted in the previous 24 hours. What should the nurse do to assist this patient with pain control? 1. Administer prescribed analgesics around the clock. 2. Administer prescribed analgesics when the patient requests something for pain. 3. Assist the patient to a more comfortable position to reduce the amount of pain. 4. Offer the patient a back rub to reduce the amount of pain. Answer: 1 Explanation: 1. Established, persistent, severe pain is more difficult to treat than pain that is at its onset. Postoperative analgesics should be administered at regular intervals around the clock to maintain a therapeutic blood level. 2. Administering analgesics as needed (prn) lowers this therapeutic level; delays in medication administration further increase pain intensity. "As needed" administration of analgesics is not recommended in the first 36 to 48 hours postoperatively. 3. The nurse could help the patient into a more comfortable position to reduce the amount of pain; however, the nurse should provide the patient with the prescribed analgesics around the clock. 4. The nurse could offer the patient a back rub to reduce the amount of pain; however, the nurse should provide the patient with the prescribed analgesics around the clock. Page Ref: 93 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

15 ..

16) An older patient is recovering from a surgical procedure. What should the nurse do to ensure the patient is comfortable? 1. Provide warm blankets. 2. Limit movement to once every eight hours. 3. Explain all activities using a loud voice. 4. Limit fluids. Answer: 1 Explanation: 1. The older patient may need extra blankets for warmth. This is what the nurse should do to ensure for the patient's comfort. 2. The patient should be carefully turned and repositioned frequently to prevent the onset of pressure ulcers. 3. The nurse should speak in a low tone and not loudly. 4. The older patient needs an adequate fluid intake and may not need to have fluids limited. Page Ref: 79 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.2 Differentiate patient risks that can be mitigated in the preoperative stage. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

16 ..

17) An older patient, recovering from surgery, is prescribed a soft diet. Which age-related change does this type of diet support? 1. Decline in gastric motility 2. Reduced intestinal absorption 3. Lactose intolerance 4. Gall bladder insufficiency Answer: 1 Explanation: 1. A soft diet helps with a change in gastrointestinal functioning in the older adult. 2. Reduced intestinal absorption is not a gastrointestinal age-related change. 3. Lactose intolerance can occur at many ages. 4. Gall bladder insufficiency is not a gastrointestinal age-related change. Page Ref: 100 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.7 Differentiate considerations for perioperative care of older adults and transgender adults. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

17 ..

18) The nurse is planning care to support the cognitive-psychosocial status for an older patient having surgery. Which intervention would be appropriate for this patient? 1. Provide time for teaching and learning. 2. Set limits with the patient. 3. Tell the patient that his physician will make all care decisions. 4. Remind the patient that the call bell is for emergencies only. Answer: 1 Explanation: 1. To support the older patient's cognitive-psychosocial status, the nurse should provide ample time for teaching and learning. 2. The nurse should not treat the older patient as a child by setting limits. 3. The nurse should not treat the older patient as a child by stating that all care decisions will be made by the physician. 4. The nurse should not treat the older patient as a child by reminding that the call bell is for emergencies only. Page Ref: 100 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Sensory/Perceptual Alterations Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 4.7 Differentiate considerations for perioperative care of older adults and transgender adults. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

18 ..

19) A patient recovering from surgery reports a pain level of 6 on a 0-10 pain scale but refuses additional pain medication to avoid becoming addicted. On which concept should the nurse focus when responding to this patient? 1. Physical dependence on pain medication is uncommon during the short-term postoperative use. 2. This patient already might have an addiction problem. 3. This patient might benefit from a placebo dose. 4. The physician should be notified to discuss pain management. Answer: 1 Explanation: 1. Patients might fear addiction or physical dependence on pain medications, especially opioids, postoperatively. The duration of use is typically short term, and this concern should be discussed, but is not anticipated to occur. 2. The patient who already has an addiction problem most likely would be requesting more medication, not refusing it. 3. The patient is verbalizing pain, so administration of a placebo is unethical, against patient rights for pain management, and should not be administered. 4. It is within the scope of the nurse to review and make decisions with the patient regarding safe use of pain medications that have been ordered by the physician. The physician does not need to be called at this time unless the nurse's interventions with the patient are unsuccessful. Page Ref: 93 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

19 ..

20) An older patient is receiving an NSAID for postoperative pain. What should the nurse assess in this patient? 1. Urine output 2. Blood pressure 3. Respiratory rate 4. Heart rate Answer: 1 Explanation: 1. NSAIDs can be given safely to older patients, but they should be observed closely for side effects, particularly gastric and renal toxicity. The nurse should monitor the patient's urine output to determine renal function. 2. NSAIDs do not usually affect blood pressure. 3. NSAIDs do not usually affect respiratory rate. 4. NSAIDs do not usually affect heart rate. Page Ref: 92 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

20 ..

21) A patient is having an epidural catheter inserted for pain control after surgery. What should the nurse realize is an advantage of using this method of pain medication for this patient? 1. Improved bowel activity 2. Faster wound healing 3. Earlier ambulation 4. Improved appetite Answer: 1 Explanation: 1. This type of intraspinal anesthesia provides safe and effective pain relief for patients of all ages with less risk of adverse effects than general anesthesia. 2. Patient-controlled epidural analgesia does not cause faster wound healing. 3. Patient-controlled epidural analgesia does not cause earlier ambulation. 4. Patient-controlled epidural analgesia does not improve appetite. Page Ref: 73 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

21 ..

22) A patient being discharged is concerned about being overmedicated because of receiving a prescription for Demerol 50 mg by mouth when 10 mg of morphine was given through the intravenous catheter in the hospital. How should the nurse respond to this patient? 1. "Oral doses need to be higher than those given through an IV." 2. "The doctor is making sure that you do not have any pain once you go home." 3. "I will get the doctor so he can explain what is going on with your condition." 4. "All patients have more pain when they go home so the doctor is making sure you have enough medication." Answer: 1 Explanation: 1. Oral doses of analgesics are not equal to parenteral doses. The oral dose of an opioid such as morphine, codeine, or hydromorphone may be two to five times higher than the parenteral dose to achieve equivalent pain relief. This is what the nurse should explain to the patient. 2. The physician is not making sure the patient has no pain at home. 3. The nurse does not need to get the physician to explain the patient's condition. 4. Not all patients have more pain when they are discharged after surgery. Page Ref: 93 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

22 ..

23) A patient is being transferred from the operating room to the recovery room. In which phase of the surgical process will the nurse in the recovery room provide care? 1. Postoperative 2. Preoperative 3. Intraoperative 4. Restorative Answer: 1 Explanation: 1. The postoperative phase begins when the patient is admitted to the recovery room and ends with the patient's recovery from the surgical intervention. 2. The preoperative phase is prior to surgery. 3. The intraoperative phase occurs during the surgery. 4. Restorative is not a phase of the surgical experience. Page Ref: 91 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

23 ..

24) An older patient is being prepared for orthopedic surgery. For what potential risk should the nurse plan care? 1. Decreased tolerance of general anesthesia 2. Prolonged effects of anesthesia because of herbal supplements 3. Wound dehiscence 4. Decreased cognitive acuity Answer: 1 Explanation: 1. Older adults have age-related changes that affect physiologic, cognitive, and psychosocial responses to the stress of surgery in addition to decreased tolerance of general anesthesia and postoperative medications and delayed wound healing. 2. No information is provided to indicate the use of herbal supplements. 3. Despite delayed wound healing, there is no information to support the increased risk for wound dehiscence. 4. Cognition remains stable in older adults, but information processing slows. Page Ref: 99 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.7 Differentiate considerations for perioperative care of older adults and transgender adults. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

24 ..

25) An older patient having preoperative diagnostic testing has an elevated carbon dioxide level. What should the nurse be monitoring for this patient? 1. Respiratory status and arterial blood gases 2. Serum potassium level 3. Serum sodium level 4. Intake and output Answer: 1 Explanation: 1. A patient with an altered carbon dioxide level could have a history of emphysema, chronic bronchitis, asthma, pneumonia, or respiratory acidosis, or it could be caused by vomiting or nasogastric suctioning. The best nursing intervention for this patient would be to monitor the patient's respiratory status and arterial blood gases. 2. A review of the potassium level is not the most beneficial to this patient at this time. 3. A review of the sodium level is not the most beneficial to this patient at this time. 4. A review of the intake and output is not the most beneficial to this patient at this time. Page Ref: 82 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

25 ..

26) An older patient recovering from surgery is given an antiemetic for nausea. Which manifestation indicates to the nurse that this patient is experiencing a possible reaction to the medication? 1. Involuntary muscle movements 2. Confusion 3. Dry mouth 4. Breakthrough vomiting Answer: 1 Explanation: 1. Antiemetics, such as Metoclopramide (Reglan) and ondansetron (Zofran) , can have tranquilizing effects as well as cause an extrapyramidal reaction. The patient would demonstrate involuntary movements, muscle tone changes, and abnormal posturing. 2. Elderly patients may also experience drowsiness, which reduces orientation, after being given antiemetics. 3. A dry mouth may be experienced as a result of having been or currently being unable to have oral intake. 4. Breakthrough vomiting is not an indication of an adverse reaction. Page Ref: 84 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

26 ..

27) The nurse is assisting a postoperative patient in using an incentive spirometer. Which postoperative complication is this nurse attempting to avoid? 1. Atelectasis 2. Deep vein thrombosis 3. Hemorrhage 4. Pulmonary embolism Answer: 1 Explanation: 1. Promoting lung expansion and systemic oxygenation of tissues is a goal in preventing atelectasis. Nursing care includes assisting with incentive spirometry. 2. Deep vein thrombosis is not related to incentive spirometer use. 3. Hemorrhage is not related to incentive spirometer use. 4. Pulmonary embolism is not related to incentive spirometer use. Page Ref: 99 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V.C.3.Value own role in preventing errors | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality & Safety; Practice-Know-How; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.6 Summarize postsurgical risks to patients including wound healing, cardiac events, respiratory events, and elimination issues. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

27 ..

28) A patient's postoperative wound has sanguineous drainage with a thick, reddish appearance. In which phase of healing is this patient's wound? 1. Inflammatory 2. Proliferative 3. Stationary 4. Remodeling Answer: 1 Explanation: 1. The inflammatory phase begins with the surgical incision. Sanguineous drainage contains both serum and red blood cells and has a thick, reddish appearance. 2. The proliferative phase begins within 2 to 3 days after surgery. 3. Stationary is not a phase of wound healing. 4. In the remodeling phase, scar tissue is remodeled by a process of collagen synthesis and breakdown to increase its strength. This phase begins about 3 weeks after surgery and can continue for 6 or more months. Page Ref: 95 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Teamwork; Practice-Know-How; Function competently within one's own scope of practice as leader or member of the healthcare team | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4.6 Summarize postsurgical risks to patients including wound healing, cardiac events, respiratory events, and elimination issues. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

28 ..

29) During the assessment of a postoperative patient's bowel sounds, the nurse auscultates absent sounds over all four abdominal quadrants. For which reason should the nurse identify interventions for this patient? 1. Paralytic ileus 2. Normal bowel function 3. The onset of flatus 4. The onset of stool Answer: 1 Explanation: 1. A distended abdomen with absent bowel sounds may indicate paralytic ileus. 2. Normal bowel sounds are low in pitch. 3. The onset or presence of flatus is accompanied by bowel sounds. 4. The onset of stool is accompanied by bowel sounds. Page Ref: 99 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.6 Summarize postsurgical risks to patients including wound healing, cardiac events, respiratory events, and elimination issues. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

29 ..

30) A patient is scheduled for extraction of a cataract. How should the nurse classify this patient's surgical procedure? 1. Minor elective 2. Minor diagnostic 3. Major constructive 4. Major elective Answer: 1 Explanation: 1. Surgical procedures are classified according to purpose, risk factor, technique, and urgency. Cataract extraction would be considered a minor elective surgery. Minor procedures carry minimal risk and minimal physical assault. 2. A minor diagnostic surgery is used to determine or confirm a condition. 3. Major constructive procedures require extensive physical assault and/or serious risk. Constructive procedures are used to build tissue/organs which are absent. 4. Major elective procedures are suggested to the patient by the physician but there is little risk if they are not performed. Page Ref: 72 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

30 ..

31) A patient who is being admitted for surgery asks why information is being collected about the use of herbal and natural supplements. How should the nurse respond to this patient? 1. "Herbal supplements may interact with anesthetic agents." 2. "Herbal remedies may cause pain relievers to be ineffective." 3. "The physician is in charge of medications." 4. "There is no need to take these preparations." Answer: 1 Explanation: 1. The use of herbal supplements must be documented prior to surgery. It is possible for these elements to interact with anesthetic agents. 2. Herbal remedies have not been shown to render analgesics ineffective. 3. Stating that the physician is in charge of medications does not adequately respond to the patient's inquiry. 4. Stating that there is no need to take these prescriptions does not adequately respond to the patient's inquiry. Page Ref: 76 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4.2 Differentiate patient risks that can be mitigated in the preoperative stage. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

31 ..

32) After complaining of discomfort from a surgical procedure, the patient voices fear of addiction with taking analgesics as prescribed. What information should be provided to the patient regarding these concerns? Select all that apply. 1. "Addiction to opioid analgesics is rare when used for short-term postoperative pain management." 2. "Psychological tolerance is not commonly experienced by patients who take narcotic analgesics during the postoperative experience." 3. "Pain tolerance and the need for opioid analgesics are individualized." 4. "Patients should be screened for addiction potential prior to being given narcotics." 5. "I'll turn the TV on to help distract you from your pain." Answer: 1, 2, 3 Explanation: 1. The use of opioid analgesics during the postoperative period is rarely associated with physical dependency concerns. 2. The use of opioid analgesics during the postoperative period is rarely associated with psychological dependency concerns. 3. The pain management needs of patients will vary and should be managed individually. 4. Screening is not routinely recommended for surgical patients. 5. This does not address the patient's need for pain control or the patient's concern over addiction from postoperative opioid analgesics. Page Ref: 93 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.5 Describe postoperative nursing care including postanesthesia care, extended care, and transfers. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

32 ..

33) An older patient who is preparing for surgery wants to wear glasses and keep a hearing aid in place until receiving anesthesia. Which nursing response demonstrates accurate therapeutic communication? 1. "I will contact the surgery department to discuss your requests." 2. "You cannot keep those in." 3. "The policies in the surgery unit will not allow it." 4. "Certainly, you can keep them for that time." Answer: 1 Explanation: 1. To decrease confusion and assist in communication, hearing aids and glasses should be used when appropriate and possible. The nurse will need to check with the surgical department first before granting the patient's wish. 2. As a patient advocate, the nurse is responsible for making an inquiry. 3. The nurse does not have the authority to make decisions on behalf of the surgical department. 4. The nurse should not give information that may be inaccurate. Page Ref: 100 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication | AACN Essentials Competencies: II.2. Demonstrate leadership and communication skills to effectively implement patient safety and quality improvement initiatives within the context of the interprofessional team | NLN Competencies: Quality & Safety; Practice-Know-How; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.7 Differentiate considerations for perioperative care of older adults and transgender adults. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

33 ..

34) A patient having a hernia repair as an outpatient asks why hospitalization afterward is not required. Which response is appropriate for the nurse to make? Select all that apply. 1. "You have less risk of getting an infection at home." 2. "You will probably be more comfortable in your own bed at home." 3. "It is cheaper for the insurance company if you go home today." 4. "The government won't let you stay." 5. "If you ask the healthcare provider, the hospital will probably let you stay." Answer: 1, 2 Explanation: 1. An advantage of outpatient surgery is reduced risk of healthcare-associated infection. 2. An advantage of outpatient surgery is less physiologic stress. 3. While it is probably cheaper for the insurance company for the patient to go home and there are governmental regulations about hospital admission and Medicare, this is not the best time to bring those concepts into the conversation. 4. While it is probably cheaper for the insurance company for the patient to go home and there are governmental regulations about hospital admission and Medicare, this is not the best time to bring those concepts into the conversation. 5. It is also not advisable to infer that the hospital has a decision to make in whether the patient stays or goes home. Page Ref: 75 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

34 ..

35) The nurse is reviewing the patient's current medications as a part of preparation for an elective surgery. What information should the nurse reinforce with the patient? 1. "Continue to take your regular prescribed dose of warfarin (Coumadin) until told otherwise." 2. "You may take your regular herbal supplements up until the day before surgery." 3. "Discontinue your antihypertensive medications two days prior to surgery." 4. "Stop taking your daily aspirin at least three days prior to surgery." Answer: 4 Explanation: 1. Anticoagulant medications, including warfarin (Coumadin), should be discontinued prior to surgery to prevent excessive blood loss during surgery. 2. Herbs or nutritional supplements that impair clotting should be discontinued 2 weeks prior to surgery. 3. Antihypertensive medications will be analyzed by the healthcare provider on an individual basis. 4. Anticoagulant medications should be discontinued prior to surgery to prevent excessive blood loss during surgery. These include aspirin. Page Ref: 78 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.2 Differentiate patient risks that can be mitigated in the preoperative stage. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

35 ..

36) The nurse suspects that a patient recovering from surgery in the postanesthesia recovery unit (PACU) is developing malignant hyperthermia. Place these interventions in the order in which they should be performed. Choice 1. Administer oxygen with a nonrebreather mask. Choice 2. Check IV access. Choice 3. Notify the anesthesia provider. Choice 4. Administer Dantrolene. Answer: 1, 2, 3, 4 Explanation: Choice 1. As soon as the nurse suspects malignant hyperthermia is occurring, oxygen should be administered by nonrebreather mask. Oxygen is necessary to support tissues that rapidly become hypermetabolic. Choice 2. The nurse should then be certain that IV access is still patent and should notify the anesthesia provider. The IV access step is done first as it is quick and if not patent, can be restarted while the anesthesia provider responds. Choice 3. The nurse should then be certain that IV access is still patent and should notify the anesthesia provider. The IV access step is done first as it is quick and if not patent, can be restarted while the anesthesia provider responds. Choice 4. Dantrolene is given IV, so a patent IV is essential. Page Ref: 73 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge: transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

36 ..

37) The nurse is preparing to teach a patient scheduled for surgery on performing diaphragmatic breathing. Place the steps of this breathing technique in the order in which the nurse should teach the patient. Choice 1. Sit up straight in bed. Choice 2. Place hands lightly on the abdomen. Choice 3. Breathe in deeply through the nose. Choice 4. Hold breath for five seconds. Choice 5. Completely exhale through pursed lips. Answer: 1, 2, 3, 4, 5 Explanation: Choice 1. The patient should be placed in high or semi-Fowler's position. Choice 2. The patient should be asked to place hands lightly on the abdomen. Choice 3. The patient should be asked to take a deep breath in through the nose. Choice 4. The patient should be asked to hold the breath to the count of five. Choice 5. The patient should be asked to exhale completed through pursed lips. Page Ref: 80 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

37 ..

38) A patient is having a surgical procedure with conscious sedation. Which patient information should be provided to the healthcare provider before administering the anesthesia to the patient? Select all that apply. 1. The patient has a history of snoring. 2. The patient drank a cup of coffee two hours ago. 3. The patient wants to be asleep for the procedure. 4. The patient's father was hypertensive. 5. The patient has a history of gout. Answer: 1, 2 Explanation: 1. While all of this information leads to a greater understanding of the patient, that the patient snores is essential information at this time. 2. While all of this information leads to a greater understanding of the patient, that the patient is not NPO is essential information at this time. 3. That the patient wishes to be asleep for the procedure is not essential information. 4. That the patient's father was hypertensive is not essential information at this time. 5. That the patient has a history of gout is not essential information at this time. Page Ref: 74 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

38 ..

39) A patient being prepared for surgery has a history of chronic obstructive pulmonary disease. Which diagnostic test may be completed prior to this patient's surgical procedure? 1. Pulmonary function tests 2. CT scan of the brain 3. Lumbar puncture 4. Abdominal MRI Answer: 1 Explanation: 1. Pulmonary function studies may be performed with patients who have chronic obstructive pulmonary disease to determine the extent of respiratory dysfunction. 2. There is no reason for a CT scan of the brain to be completed. 3. There is no reason for a lumbar puncture to be completed. 4. There is no reason for an abdominal MRI to be completed. Page Ref: 82 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4.3 Describe the preanesthesia phase, preadmission testing, and procedures for the day of surgery. MNL Learning Outcome: 2. Apply the nursing process to the care of the patient during the preoperative stage.

39 ..

40) An older patient recovering from total hip replacement surgery 8 hours ago has not been able to void spontaneously. Which actions should the nurse take to assist this patient? Select all that apply. 1. Increase fluids. 2. Turn onto the left side. 3. Palpate the bladder for distention. 4. Insert an indwelling urinary catheter. 5. Complete a bladder scan at the bedside. Answer: 1, 3, 5 Explanation: 1. Promote fluid intake as allowed, monitoring intake and output. 2. Turning onto the left side will not promote urinary elimination. 3. Assess for bladder distention if the patient has not voided within 7 to 8 hours after surgery. 4. Urinary catheterizations should be avoided to reduce the potential for urinary tract infections and urethral trauma. 5. Use a portable ultrasound scanner to determine the amount of urine in the bladder. Page Ref: 99 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.6 Summarize postsurgical risks to patients including wound healing, cardiac events, respiratory events, and elimination issues. MNL Learning Outcome: 4. Apply the nursing process to the care of the patient during the postoperative and postsurgical stages.

40 ..

41) The intraoperative nurse is caring for a patient in the maintenance phase of anesthesia. Which actions should the nurse prepare to provide to the patient at this time? Select all that apply. 1. Prepare the skin. 2. Assess oxygen saturation level. 3. Participate in the surgical procedure. 4. Position the patient for the surgical procedure. 5. Measure blood pressure and heart rate. Answer: 1, 3, 4 Explanation: 1. During the maintenance phase of anesthesia, the skin is prepared. 2. The anesthesiologist monitors the patient's blood pressure, heart rate, and oxygen saturation level at this time. 3. During the maintenance phase of anesthesia, the surgery is performed. 4. During the maintenance phase of anesthesia, the patient is positioned. 5. The anesthesiologist monitors the patient's blood pressure, heart rate, and oxygen saturation level at this time. Page Ref: 88 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.4 Outline aseptic practices, safety, and patient care during surgery. MNL Learning Outcome: 3. Apply the nursing process to the care of the patient during the intraoperative stage.

41 ..

42) A patient who has reacted poorly to general anesthesia in the past is scheduled for surgery to repair a rotator cuff tear. For which types of anesthesia should the nurse prepare educational materials for this patient? Select all that apply. 1. Spinal 2. Topical 3. Epidural 4. Nerve block 5. Local nerve infiltration Answer: 3, 4 Explanation: 1. Spinal anesthesia is effective for approximately 90 minutes. Surgeries of the lower abdomen, perineum, and lower extremities are likely to use this type of regional anesthesia. 2. Topical anesthesia would not be an option for this case. 3. Epidural blocks are local anesthetic agents injected into the epidural space, outside the dura mater of the spinal cord. It is indicated for surgeries of the shoulders. 4. Nerve blocks are accomplished by injecting an anesthetic agent at the nerve trunk to produce a lack of sensation over a specific larger area, such as an extremity. 5. Local nerve infiltration is achieved by injecting an anesthetic agent around a local nerve to suppress sensation over a limited area of the body. This technique may be used when a skin or muscle biopsy is obtained or when a small wound is sutured. Page Ref: 73 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

42 ..

43) The nurse determines that a patient recovering from spinal anesthesia is experiencing complications from the anesthesia. Which should the nurse expect to be provided to this patient? Select all that apply. 1. Caffeine 2. Analgesics 3. Intravenous fluids 4. Epidural blood patch 5. Vasoactive medication Answer: 1, 2, 3, 4 Explanation: 1. Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include caffeine. 2. Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include analgesics. 3. Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include hydration. 4. Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include an epidural blood patch. 5. Vasoactive medications are used if hypotension occurs. Page Ref: 73 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

43 ..

44) While the nurse is assisting a patient recovering from epidural anesthesia to ambulate, the patient becomes dizzy and has a blood pressure of 78/48 mmHg. What actions should the nurse take? Select all that apply. 1. Notify the anesthesiologist. 2. Notify the pharmacy to obtain atropine. 3. Continuously monitor blood pressure. 4. Prepare to administer intravenous fluids. 5. Prepare to administer vasoactive medications. Answer: 1, 3, 4, 5 Explanation: 1. Hypotension is common with epidural. Blood pressure should be monitored and, if critical hypotension occurs, the anesthesia provider should be alerted and expected to increase intravenous fluids and administer vasoactive medications. 2. Atropine is not indicated in the treatment of this adverse effect of epidural anesthesia. 3. Hypotension is common with epidural. Blood pressure should be monitored and, if critical hypotension occurs, the anesthesia provider should be alerted and expected to increase intravenous fluids and administer vasoactive medications. 4. Hypotension is common with epidural. Blood pressure should be monitored and, if critical hypotension occurs, the anesthesia provider should be alerted and expected to increase intravenous fluids and administer vasoactive medications. 5. Hypotension is common with epidural. Blood pressure should be monitored and, if critical hypotension occurs, the anesthesia provider should be alerted and expected to increase intravenous fluids and administer vasoactive medications. Page Ref: 73 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.1 Compare various methods of and settings for surgical procedures, types of anesthesia, and perioperative patient safety. MNL Learning Outcome: 1. Recognize settings, types of anesthesia, and safety for patients undergoing surgery.

44 ..

45) The nurse is preparing to assist during a surgical procedure. For which reason should the surgical scrub be completed? Select all that apply. 1. Sterilize the skin. 2. Apply an antimicrobial residue on the skin. 3. Prevent the need to wear surgical gloves during the procedure. 4. Remove dirt, skin oils, and transient microorganisms from the skin. 5. Improve patient safety by removing the number of organisms on personnel. Answer: 2, 4, 5 Explanation: 1. The skin cannot be sterilized. 2. One purpose of a surgical scrub is to leave an antimicrobial residue on the skin to inhibit the growth of microbes for several hours. 3. A surgical scrub does not take the place of wearing surgical gloves during an operative procedure. 4. One purpose of a surgical scrub is to remove dirt, skin oils, and transient microorganisms from the skin. 5. One purpose of a surgical scrub is to improve patient safety by removing the number of organisms on personnel. Page Ref: 87 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4.4 Outline aseptic practices, safety, and patient care during surgery. MNL Learning Outcome: 3. Apply the nursing process to the care of the patient during the intraoperative stage.

45 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 5 Palliative and End-of-Life Care 1) The family member of a terminally ill patient wants to donate a million dollars to the hospital if the patient can be cured. In which stage of Kübler-Ross's stages of loss is the family member demonstrating? 1. Bargaining 2. Denial 3. Anger 4. Acceptance Answer: 1 Explanation: 1. Bargaining is an attempt to postpone or in some way affect the reality of the loss. 2. The family member is not expressing denial. 3. The family member does not appear to be angry. 4. The family member is not expressing acceptance. Page Ref: 110 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.C.7. Recognize personally held values and beliefs about the management of pain or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

1 ..

2) A patient whose spouse died a year ago is starting a new job and plans to move to a new community. In which stage of Bowlby's theory of attachment is this patient demonstrating? 1. Detachment 2. Protest 3. Despair 4. Anger Answer: 1 Explanation: 1. In the stage of detachment, the person realizes the permanence of the loss and expresses readiness to move forward. This is what the patient is doing when planning to begin a new job and move to a new community. 2. The protest phase is marked by a lack of acceptance of the loss. 3. In despair, the person's behavior becomes disorganized. 4. Anger is not a stage within Bowlby's theory of attachment. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

2 ..

3) A patient has decided to join a support group for surviving spouses of victims of violent crime. According to Engel's theory of grief and loss, in which stage is this patient? 1. Restitution 2. Acute grief 3. Shock and disbelief 4. Denial Answer: 1 Explanation: 1. During restitution, the mourner continues to feel a painful void, is preoccupied with thoughts of the loss, and may join a support group or seek other social support for coping with the loss. 2. Acute grief is initiated by shock and disbelief. 3. Acute grief is initiated by shock and disbelief. 4. Acute grief is initiated by shock and disbelief, which may manifest as denial. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

3 ..

4) A 30-year-old terminally ill patient is concerned about how her 7-year-old child will perceive her death. What advice from the nurse would be most beneficial? 1. Children of this age recognize that death is permanent. 2. Children of this age emotionally distance themselves from the death. 3. Because the child fears separation, the patient can prepare the child by explaining that death is permanent. 4. Children of this age think death is sleeping. Answer: 1 Explanation: 1. Age is a great determinant of beliefs about death. Children of this age understand the finality of death. 2. At the age of 7, children do not have the emotional maturity to distance themselves from death. 3. The ability to understand separation has been mastered by the age of 7. 4. Children of this age do not think that death is sleeping. Page Ref: 110 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

4 ..

5) A patient says that her estranged spouse died a little over a year ago and states, "I am not sure why this is so difficult. I really couldn't stand him near the end." Which response by the nurse is most appropriate? 1. "Sometimes a rocky relationship with someone at the time of their death can affect your ability to grieve." 2. "You seem angry." 3. "You should contact a therapist." 4. "You are just entering the grief process. Things will get better." Answer: 1 Explanation: 1. An ambivalent relationship prior to the loss can affect a person's ability to grieve. 2. The patient does not seem angry. 3. It is inappropriate for the nurse to refer the patient to a therapist. 4. As the death occurred over a year ago, the patient is experiencing impaired grieving. Page Ref: 111 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

5 ..

6) A terminally ill patient is demonstrating signs of spiritual distress. Which should the nurse do first to assist this patient? 1. Use the FICA assessment. 2. Help the patient with guided imagery. 3. Offer to pray with the patient. 4. Leave the patient alone. Answer: 1 Explanation: 1. Because the nurse often feels uncertain about implementing interventions that would be helpful to the patient responding to a loss, the FICA assessment can be used to assess a patient's spiritual or religious practices. 2. The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone. 3. The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone. 4. The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone. Page Ref: 112 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Religious and Spiritual Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

6 ..

7) After an unsuccessful resuscitation attempt, a patient dies. What should the nurse do first? 1. Document the time of death. 2. Notify the funeral home. 3. Contact the physician. 4. Contact the orderly for transport to the morgue. Answer: 1 Explanation: 1. After death, the time must be recorded in the patient's record. 2. Notification of the funeral home must wait pending a decision about the need for an autopsy as well as a review of the family's wishes. 3. After documentation is completed, the attending physician will require notification. 4. The body can be transported to the morgue after family members have been notified and allowed to see their loved one. Page Ref: 118 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

7 ..

8) A terminally ill patient is experiencing secretions pooling in the back of the throat. What can the nurse do to help this patient feel more comfortable? 1. Raise the head of the bed. 2. Gently massage the patient. 3. Provide frequent small sips of fluids. 4. Provide oral care. Answer: 1 Explanation: 1. The nurse should reposition the patient and raise the head of the bed if fluids accumulate in the upper airways and back of the throat. 2. Gentle massage helps with accumulating edema of the extremities. 3. Small sips of fluids help with the discomfort of drying oral mucous membranes. 4. Oral care helps with the discomfort of drying oral mucous membranes. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

8 ..

9) A terminally ill patient experiencing dyspnea reports a feeling of suffocation. What can the nurse do to assist this patient? 1. Keep the room cool with a slight breeze. 2. Increase the heat in the room. 3. Provide additional intravenous fluids. 4. Assist the patient to a sitting position out of bed. Answer: 1 Explanation: 1. Nursing care to improve respirations includes keeping the head of the bed elevated, keeping the room cool, and providing a breeze from a fan. 2. Raising the temperature in the room will not reduce the feeling of suffocation. 3. Providing additional intravenous fluids may contribute to fluid accumulation in the lungs and contribute to the feeling of suffocation. 4. The patient is terminally ill with dyspnea and therefore should not be ambulating or sitting out of bed. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

9 ..

10) A terminally ill patient nearing end of life is dehydrated and complains of being thirsty. What can the nurse do to make the patient more comfortable? 1. Provide oral care every 2 hours. 2. Increase intravenous fluids. 3. Raise the head of the bed. 4. Begin enteral feedings. Answer: 1 Explanation: 1. Dehydration in the patient nearing death causes discomfort primarily from dry mouth and thirst. The patient should be given oral care at least every 2 hours, and more often if the patient is breathing through the mouth. 2. Increasing intravenous fluids could cause peripheral and lung edema. 3. Raising the head of the bed helps with dyspnea, not dehydration. 4. Enteral feedings could cause discomfort and would not help with the discomfort of a dry mouth and thirst. Page Ref: 118 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

10 ..

11) A competent older adult patient has a living will stating that resuscitation and heroic life support measures are to be avoided even though family members are not supportive of this directive. Which action by the nurse is the most appropriate? 1. Place the document on the chart. 2. Contact the Social Services department. 3. Notify the hospital attorney. 4. Explain to the patient that the conflict could invalidate the document. Answer: 1 Explanation: 1. The patient is competent, and the wishes of the patient must take priority. The document should first be placed on the chart and the physician notified. 2. If there are concerns about the authenticity of the document, the Social Services department will need to be contacted. 3. If there are concerns about the authenticity of the document, the unit supervisor or hospital attorney will need to be contacted. 4. A lack of support by the family does not invalidate the document. Page Ref: 116 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

11 ..

12) At the time of admission, a patient with a terminal illness appoints an adult daughter to make health-related decisions if the patient becomes incapacitated. What should the nurse realize this patient is specifically describing? 1. Healthcare surrogate 2. Living will 3. Durable power of attorney 4. Advance directive Answer: 1 Explanation: 1. The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. 2. The living will provides written directions about life-prolonging decisions. 3. The durable power of attorney delegates the authority to make health, financial, and/or legal decisions on an individual's behalf. 4. Advance directives are legal documents that allow a person to plan for healthcare and/or financial affairs in the event of incapacity. They include living wills, healthcare surrogates, and durable power of attorney. Page Ref: 116 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

12 ..

13) A terminally ill patient and the family agree that the physician will write a do-notresuscitate order for the patient. What should the nurse implement when following this order? 1. Do not call a code if the patient stops breathing or the heart stops beating. 2. Call a code only if the patient stops breathing. 3. Call a code only if the patient's heart stops beating. 4. Withhold food and fluids but provide pain medication. Answer: 1 Explanation: 1. A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. 2. This order is based on the wishes of the patient and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest. 3. When implementing this order, the nurse would not call a code if the patient stops breathing or the heart stops beating. 4. Withholding food and fluids but providing pain medication would be elements of a comfortmeasures-only order. Page Ref: 116 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

13 ..

14) A terminally ill patient who does not have an advance directive or do-not-resuscitate order in place stops breathing. What should the nurse do to assist this patient? 1. Call a code. 2. Initiate a slow code. 3. Contact the physician to assess the patient for death. 4. Contact the nursing supervisor. Answer: 1 Explanation: 1. Without an advance directive or do-not-resuscitate order, the nurse is legally responsible for calling a code on the terminally ill patient who has stopped breathing. 2. To initiate a slow code would be malpractice. 3. The nurse needs to call a code, not call the physician. 4. The nurse needs to call a code, not call the nursing supervisor. Page Ref: 116 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

14 ..

15) A terminally ill patient is receiving palliative care. What type of care should the nurse anticipate this patient will receive? 1. Alleviating suffering and enhancing quality of life. 2. Reducing pain and preventing medical complications. 3. Controlling side effects of illness while postponing death. 4. Withdrawing all medical care to allow natural death. Answer: 1 Explanation: 1. The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. 2. Medical complications can be controlled but not prevented. 3. The purpose is not specifically to postpone death. 4. Withdrawing all medical care would be inappropriate as it would cause more suffering. Page Ref: 113 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.2 Explain the concept of palliative care and the nurse's role in care of the patient and family. MNL Learning Outcome: 2. Integrate collaborative interventions to manage and improve outcomes for the patient in palliative care and care at end-of-life.

15 ..

16) A patient asks the nurse what it means to have hospice care at home. What should the nurse respond to this patient? 1. "Hospice makes sure that you are comfortable at home." 2. "Hospice care helps cure your illness." 3. "Hospice care is for patients who will be sick for longer than a year." 4. "Hospice care means your physical needs will be met." Answer: 1 Explanation: 1. Hospice care focuses on comfort care versus curative care. 2. The focus of hospice is on care, not cure. It is care for patients with limited life expectancy. 3. Patients receiving hospice care are generally defined as those who have a prognosis of 6 months or less if their terminal disease runs a normal course. 4. The care plan includes both the patient and family/caregiver as the unit of care, and the care plan is written to meet their values and goals. Page Ref: 115 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

16 ..

17) A patient receiving palliative care for a chronic illness asks the nurse if the new medication is going to cure the disease. Which is the nurse's best response? 1. "It will help you be more comfortable. I don't think it's going to cure the disease." 2. "Of course it's going to cure the disease." 3. "If you believe it will cure the disease, then it will." 4. "I don't think it's going to help or hurt at this time." Answer: 1 Explanation: 1. In palliative care, the nurse needs to be honest with the patient and explain that the medication will help with comfort, but will not cure the chronic illness. 2. In palliative care, the nurse needs to be honest with the patient and explain that the medication will not cure the disease. 3. The nurse should not approach care as curative because this could rob the patient of time and closure at the end of life. 4. The nurse has no way of knowing whether the medication will help or hurt the patient. Page Ref: 113 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.2 Explain the concept of palliative care and the nurse's role in care of the patient and family. MNL Learning Outcome: 2. Integrate collaborative interventions to manage and improve outcomes for the patient in palliative care and care at end-of-life.

17 ..

18) A patient is explaining experiences after the sudden death of a family member a few years ago. If Elizabeth Kübler-Ross's sequence is applied, in which order did the patient experience the stages of death and dying? Rank the patient's statements in the order they would have been made. Place in order the steps of the process. Choice 1. "I have to admit I tried to make a deal with God." Choice 2. "I'm going to try to use my experience to help other people." Choice 3. "I cannot get my mind around it. I still keep waiting for them to come home." Choice 4. "I can hardly get out of bed because I just want to sleep." Choice 5. "I just feel so angry that I was left." Answer: 3, 5, 1, 4, 2 Explanation: Choice 1. Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Bargaining is the third stage. Choice 2. Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Acceptance is the final stage. Choice 3. Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Denial is the first stage. Choice 4. Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Depression is the fourth stage. Choice 5. Elizabeth Kübler-Ross's research about death and dying provided a framework for gaining insight about the stages of coping with an impending or actual loss. Anger is the second stage. Page Ref: 110 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.C.7. Recognize personally held values and beliefs about the management of pain or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

18 ..

19) A patient who is nearing death from a terminal illness is experiencing secretions in the back of the throat and dyspnea. Which medication should the nurse provide to assist this patient? Select all that apply. 1. Oxygen 2. Morphine 3. Atropine 4. Scopolamine 5. Demerol Answer: 1, 2, 3, 4 Explanation: 1. As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with oxygen. 2. As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with opioids. 3. As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with medications that reduce secretions, such as atropine. 4. As death nears, respirations often become fast or slow, shallow, and labored. The patient may have apnea or Cheyne-Stokes respirations. Fluid may accumulate in the lungs, causing crackles, especially in patients who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with medications that reduce secretions, such as scopolamine. 5. Meperidine (Demerol) is not useful for chronic pain because it has a short half-life and a toxic metabolite that can cause irritability and seizures. Page Ref: 122 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life. 19 ..

20) The family of a patient who is nearing death has insisted on intravenous fluids. Which finding should the nurse expect when assessing this patient? Select all that apply. 1. Inspiratory and expiratory crackles in all lung fields. 2. Increasing edema in the patient's ankles and feet bilaterally. 3. Ascites. 4. Weight loss of 6 pounds from last week. 5. Vomited three times during the previous shift. Answer: 1, 2, 3, 5 Explanation: 1. Initiating intravenous fluids for hydration purposes in the dying patient may increase fluid in the lungs. 2. Initiating intravenous fluids for hydration purposes in the dying patient may lead to peripheral edema. 3. Initiating intravenous fluids for hydration purposes in the dying patient may lead to ascites. 4. Fluids will cause a weight gain. 5. Initiating intravenous fluids for hydration purposes in the dying patient may lead to vomiting. Page Ref: 118 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

20 ..

21) A patient of Mexican American descent is dying. Which statements by the patient's only son are expected? Select all that apply. 1. "We have already notified our priest about Dad's condition." 2. "When the time of death gets closer, we would like him transferred to the inpatient hospice unit at the hospital." 3. "My sister is pregnant, so she really can't help with his care." 4. "My family members will be here at the house a lot right now." 5. "We don't want to worry him, so if there is any change in his condition, please talk to me about it." Answer: 1, 4 Explanation: 1. It is important that the patient's priest be notified. 2. It would be unusual for the family of this patient to express the wish to transfer the patient from home to a hospital. Mexican American families often prefer that the patient die at home. 3. There is no evidence that pregnant women do not care for dying persons or attend funerals. 4. Mexican Americans may be more likely to choose to be cared for at home. 5. There is no evidence that the Mexican American family may want to protect the patient from the seriousness of illness. Page Ref: 113 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.C.6. Willingly support patient-centered care for individuals and groups whose values differ from own | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

21 ..

22) A patient diagnosed with testicular cancer does not believe he has cancer. The nurse realizes that the patient may be progressing through the stages of grief. Place in order the stages of grief. Choice 1. Depression Choice 2. Acceptance Choice 3. Anger Choice 4. Denial Choice 5. Bargaining Answer: 4, 3, 5, 1, 2 Explanation: Choice 1. The fourth stage, depression, occurs when the patient realizes the full impact of the loss. Choice 2. The final stage is acceptance and occurs when the patient accepts the conditions of the illness and begins to plan or hope for the future. A patient may or may not experience all of the stages in this process. Choice 3. The second stage is anger, when the patient demonstrates anger over the situation. Choice 4. The patient is currently in the stage of denial by refusing to accept the diagnosis. Kübler-Ross's stages of grieving begin with denial. Choice 5. The third stage is bargaining, in which the patient may make an agreement with God or another supreme being. Page Ref: 110 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.C.7. Recognize personally held values and beliefs about the management of pain or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

22 ..

23) The nurse suspects a patient is in the final stages of the dying process. What manifestation did the nurse assess in this patient? Select all that apply. 1. Change in level of consciousness 2. Sudden increase in taste and smell 3. Urinary incontinence 4. Increased blood pressure 5. Irregular heart rate Answer: 1, 3, 5 Explanation: 1. Assessment findings consistent with the late stages of the dying process include a change in level of consciousness. 2. There is a decrease, not an increase, in taste and smell. 3. Assessment findings consistent with the late stages of the dying process include incontinence of bowel and bladder. 4. Blood pressure will decrease. 5. Assessment findings consistent with the late stages of the dying process include an irregular heart rate. Page Ref: 117 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

23 ..

24) A patient diagnosed with terminal cancer learns about a living will. Which patient statement indicates that additional teaching is required? Select all that apply. 1. "A living will is a document in which I designate someone to make healthcare-related decisions for me in the event I become unconscious." 2. "A living will is a document in which I designate someone to make healthcare and legal decisions for me in the event I become unconscious." 3. "A living will is a document in which I designate my personal wishes and which directions to follow in the event I become unconscious." 4. "A living will is a document in which I designate which directions to follow in the event I become unconscious, but the directions can be modified by my family." 5. "A living will is a document in which my family designates someone to make decisions for me in the event I become unconscious." Answer: 1, 2, 4, 5 Explanation: 1. A healthcare surrogate is an individual that the patient designates to make healthcare decisions for the patient in the event the patient is unable to do so. 2. Durable power of attorney is a document that delegates the authority to make legal, healthcare, and financial decisions for the patient in the event the patient is unable to do so because of a change in health status. 3. A living will is a document in which the patient designates those wishes and directions to follow in the event of terminal illness or permanent unconsciousness. 4. A living will cannot be modified by the patient's family. A living will is not created for another person; therefore, the family cannot make a living will for a patient. 5. A living will is not created by the patient's family. Page Ref: 116 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

24 ..

25) The nurse is instructing others on the use of hospice care. Which statements would indicate to the nurse that the teaching session has been effective? Select all that apply. 1. "Hospice care is designed for individuals with a terminal prognosis who cannot stay at the hospital." 2. "Hospice care is designed for individuals with a terminal prognosis who decide to spend their final days at home with their families." 3. "Hospice care is designed for individuals with a terminal prognosis who decide to stay in the hospital for symptom management." 4. "Hospice care is designed for individuals with a terminal prognosis who have to go into a hospice center for proper symptom management." 5. "Hospice care is designed for individuals with a terminal prognosis who decide to receive treatment for their symptoms at home, the hospital, or the hospice center." Answer: 2, 3, 5 Explanation: 1. Hospice care can be received in the home, hospital, hospice center, or community. 2. Hospice care is a philosophy of care designed for the individual with a terminal prognosis and the individual's family members. Hospice care can be received in the home, hospital, hospice center, or community. Hospice services begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient. 3. Hospice care can be received in the home, hospital, hospice center, or community. Hospice services begin when the patient has 6 months or less to live and ends with the family 1 year after the death of the patient. 4. Hospice care can be received in the home, hospital, hospice center, or community. 5. Hospice care can be received either at home, the hospital, hospice center, or the community. Page Ref: 115 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current Best Practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

25 ..

26) A young adult male patient diagnosed with terminal pancreatic cancer believes that if his hair grows, God will cure him. What should the nurse realize this patient is demonstrating? Select all that apply. 1. The patient is having delusions and is using religious beliefs to block his loss. 2. The patient is bargaining and is postponing his loss. 3. The patient is in denial, and his religious beliefs block his loss. 4. The patient is normal; bargaining with God for physical healing reflects a stage of grieving. 5. The patient is feeling anger and is using his religious beliefs to project his loss. Answer: 2, 4 Explanation: 1. The patient is not delusional and is not using religious beliefs to block the loss. 2. Bargaining is one stage within Kübler-Ross's stages of grieving in which the person makes a bargain with God and expresses the willingness to do anything to postpone the reality of the loss or change the prognosis. 3. The patient is also not in denial and using his religious beliefs to block the loss. 4. Bargaining is one stage within Kübler-Ross's stages of grieving in which the person makes a bargain with God and expresses the willingness to do anything to postpone the reality of the loss or change the prognosis. 5. Bargaining with God is not a demonstration of anger. Page Ref: 110 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.C.7. Recognize personally held values and beliefs about the management of pain or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

26 ..

27) A patient who had a below-the-knee amputation 2 months ago is seen walking with a new limb prosthesis and returning to work. What does the nurse realize about this patient? 1. The patient has completed the work of mourning the loss of the leg. 2. The patient is having difficulty with grief. 3. The patient is in denial. 4. The patient is forgetting about the disease that caused the loss of the limb. Answer: 1 Explanation: 1. In one theory of the process of loss, the person gradually withdraws attachment to the lost object or person. The period of mourning, or work of mourning, ends and the person reaches a state of completion. This is the time when the patient may be ready to move on and make a change such as using a prosthesis or return to activities they were involved in before the loss. 2. The patient's actions indicate a positive adaptation, not an inability to manage grief. 3. Denial is manifested by behaviors or statements indicating the patient cannot believe the event has occurred. 4. There is inadequate information provided to infer the patient has forgotten about the disease which caused the loss of the limb. Further, forgetting an event of this magnitude is extremely unlikely. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

27 ..

28) A patient whose spouse has died asks how long it will take to feel like living again. Which stages of Bowlby's grieving process does this patient have to work through? Select all that apply. 1. Denial 2. Despair 3. Detachment 4. Protest 5. Restitution Answer: 2, 3, 4 Explanation: 1. Denial is associated with feelings of disbelief. 2. The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate the event is acknowledged. 3. The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate the event is acknowledged. 4. The theorist Bowlby believes that a person needs to work through the three phases of grief before being able to move beyond the grief process. These three phases are protest, despair, and detachment. The patient's responses indicate the event is acknowledged. 5. Restitution is a stage in Engel's theory of loss. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

28 ..

29) The spouse of a former patient reports joining a support group to help with the loss of the patient. Which phase of Engel's grief process is the spouse demonstrating? 1. Acute 2. Restitution 3. Long-term 4. Resolution Answer: 2 Explanation: 1. The acute phase is initiated by shock and disbelief, manifested by denial. 2. According to Engel, there are three phases of the grief process: acute, restitution, and longterm. It is during restitution that the surviving spouse might join a support group to help cope with the loss. 3. During the long-term phase, the individual begins to come to terms with the loss and renew activities. 4. Resolution is associated with the acceptance of the loss but is not one of the phases in Engel's grief process. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

29 ..

30) A patient getting a divorce is concerned about managing financially and emotionally. Which aspect of Caplan's stress and loss theory is this patient demonstrating? 1. Living without the assets and guidance 2. Psychic pain 3. Reduced problem-solving ability 4. Emotional turmoil Answer: 1 Explanation: 1. According to Caplan's theory of stress and loss, there are three factors that influence a person's ability to deal with a loss. This patient is demonstrating the factor of living without the assets and guidance of the lost person or resource. 2. Psychic pain encompasses the loss of the bond and the pain associated with coming to terms with the loss. 3. The patient is not demonstrating an inability to handle problems according to the data provided. 4. Emotional turmoil is not a specific factor cited in Caplan's theory. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

30 ..

31) A patient tells the nurse, "My husband left me to be with God." What should the nurse realize this patient is demonstrating? 1. Coping 2. Denial 3. A regional difference in the way death is expressed 4. A cultural rite related to death Answer: 3 Explanation: 1. This patient statement does not indicate coping. 2. This patient statement does not indicate denial. 3. Differences in the way death is expressed in the United States include "passed away," "died peacefully," "departed this life," "went home to be with God," and "passed from this life." 4. This patient statement does not reflect a cultural rite. Page Ref: 111 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Religious and Spiritual Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

31 ..

32) The nurse is assessing a dying patient's spiritual beliefs about death. Which acronym represents topics the nurse can use to help with this assessment process? 1. ABC 2. FICA 3. DABDA 4. RACE Answer: 2 Explanation: 1. ABC represents airway, breathing, and circulation, and is not related to assessing a dying patient's spiritual beliefs about death. 2. Faith, influence, community, and address form the acronym FICA. These topics can help the nurse move through the spiritual assessment process with a patient. 3. DABDA represents denial, anger, bargaining, despair, and acceptance and are Kübler-Ross's stages of grieving. 4. RACE represents the emergency evacuation procedure during a fire: remove, activate, confine, and extinguish. This acronym is not related to this situation. Page Ref: 112 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Religious and Spiritual Influences on Health Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

32 ..

33) A patient states, "My husband is the person you should talk with if I am not able to make decisions about my care." What should the nurse realize the spouse has been designated to be? 1. The person who has the patient's living will 2. The healthcare surrogate 3. The person with the durable power of attorney 4. Nothing more than the spouse Answer: 2 Explanation: 1. The patient would have been asked to provide a copy of a living will or documentation of any legal designations, such as a durable power of attorney for healthcare. 2. A healthcare surrogate is the person selected by the patient to make medical decisions when the patient is no longer able to make them for him- or herself. 3. Durable power of attorney does not confer decision-making power related to health. This specifically needs to be a healthcare power of attorney. 4. A healthcare surrogate is the person selected to make medical decisions when a person is no longer able to make them for him- or herself. The patient would have been asked to provide a copy of a living will or documentation of any legal designations, such as a durable power of attorney for healthcare. Page Ref: 116 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

33 ..

34) The family of a dying patient wants to help relieve the patient's progressive dyspnea. What should the nurse instruct the family to do for the patient? 1. Lower the head of the bed. 2. Raise the head of the bed. 3. Suction the patient as much as possible. 4. Perform chest physiotherapy. Answer: 2 Explanation: 1. Nursing care to improve respirations does not include lowering the head of the bed. 2. Nursing care to improve respirations includes raising the head of the bed. 3. Suctioning would be considered an advanced care measure and is not indicated in the scenario. 4. Chest physiotherapy would be considered an advanced care measure and is not indicated in the scenario. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

34 ..

35) The family thinks a dying patient is in pain because of constant moaning. What should the nurse realize this family is doing? 1. Overreacting. 2. Asking for more pain medication for the patient. 3. Not understanding that moaning can be agitation in the patient. 4. Considering moaning to be a sign the patient is recovering. Answer: 3 Explanation: 1. The responses by the family are typical and do not reflect excessive concern. 2. There is no indication that the family is requesting pain medication. 3. Moaning, groaning, and grimacing often accompany agitation and may be misinterpreted as pain. 4. The family thinks she is in pain, which would not indicate an improvement in status. Page Ref: 118 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

35 ..

36) A dying patient does not want family members to leave. What should the nurse realize this patient is demonstrating? 1. Fear of dying alone. 2. The anticipation of improving in health. 3. The need for the family to see the patient improve. 4. The desire to prolong life. Answer: 1 Explanation: 1. Family members are often afraid to be present at the time of death; yet, dying alone is the greatest fear expressed by patients. 2. There is no information provided to indicate there will be a recovery or improvement in the patient's condition. 3. There is no information provided to indicate there will be a recovery or improvement in the patient's condition. 4. While the patient may wish to live longer, these behaviors are consistent with a fear of dying alone. Page Ref: 118 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: End of Life Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

36 ..

37) The nurse who provided care to a terminally ill patient does not want to spend any time with the grieving family and begins to provide care to another patient. What is this nurse demonstrating? 1. Empathy 2. Apathy 3. Over-emotionality 4. Blunting Answer: 4 Explanation: 1. Empathy refers to the provision of emotional support that promotes a feeling of acceptance to the patient. 2. Apathy is an emotion characterized by a lack of concern and involvement. 3. Over-emotionality is not a recognized term. 4. Blunting is a problem often experienced by nurses who provide care to the terminally ill. The nurse may not be able to handle personal emotions appropriately right after the death, and this is a coping mechanism. Page Ref: 119 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.C.7. Recognize personally held values and beliefs about the management of pain or suffering | AACN Essentials Competencies: VIII.7. Identify personal, professional and environmental risks that impact personal and professional choices and behaviors | NLN Competencies: Context and Environment; Ethical Comportment; Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion. | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

37 ..

38) A patient who has recently lost a spouse is unable to cry. What should the nurse realize this patient is at risk for developing? 1. Psychological issues 2. Depression 3. Over-emotionality 4. Somatic symptoms Answer: 4 Explanation: 1. There is no indication this patient will face an increased risk for the development of psychological issues. 2. There is no indication this patient will face an increased risk for the development of depression. 3. Crying is considered a typical and expected part of the grief reaction in most grief theories. 4. The inability to express grief can lead to the onset of somatic, or physical, symptoms. Page Ref: 120 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

38 ..

39) A preoperative patient says, "I hope I wake up after surgery. I don't know what my family would do if I didn't." Which potential issue is this patient demonstrating? 1. Coping 2. Chronic sorrow 3. Anticipatory grieving 4. Death anxiety Answer: 3 Explanation: 1. This patient is expressing a feeling, not demonstrating coping. 2. This patient is not demonstrating chronic sorrow, which is a "cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced in response to continual loss, throughout the trajectory of an illness or disability." 3. Anticipatory grieving is a cluster of predictable responses to an anticipated loss. These responses include the range of feelings experienced by the individual or family preoccupied with an anticipated loss. 4. This patient is not experiencing death anxiety, which is worry or fear related to death or dying. It may be present in patients who have an acute life-threatening illness, who have a terminal illness, who have experienced the death of a family member or friend, or who have experienced multiple deaths in the same family. Page Ref: 109 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5.1 Differentiate theories of loss and grief and outline factors affecting responses to loss. MNL Learning Outcome: 1. Consider theories and factors related to loss and grief.

39 ..

40) A patient with a terminal illness plans to take an overdose of pain medication and end it all. How should the nurse respond to this patient's plan? Select all that apply. 1. "Do you have a living will?" 2. "Have you assigned durable power of attorney to anyone?" 3. "Have you considered a healthcare surrogate?" 4. "Have you researched methods for self-euthanasia?" 5. "Have you talked with your healthcare provider about orders for life-sustaining treatment?" Answer: 1, 2, 3, 5 Explanation: 1. A living will is a document that provides written directions about life-prolonging procedures to follow when an individual can no longer communicate in a life-threatening situation. 2. Durable power of attorney is a document that can delegate the authority to make healthcare decisions. 3. A healthcare surrogate is a person selected to make medical decisions when the patient is no longer able to do so. 4. Euthanasia is not supported by the American Nurses Association and would be inappropriate to discuss with the patient. 5. A physician order for life-sustaining treatment (POLST) is a form for patients with serious, progressive, chronic illnesses that translates their wishes regarding life-sustaining treatment into actionable medical orders. Page Ref: 116 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 4. Recognize the legal and ethical considerations involved in providing palliative care and care at end-of-life.

40 ..

41) A patient who is nearing the end of life is irritable and uncomfortable in bed. Which action should the nurse take to make the patient more comfortable? Select all that apply. 1. Raise the head of the bed. 2. Apply bed pads over the linens. 3. Gently massage the extremities. 4. Reduce the amount of pain medication. 5. Use a draw sheet to turn the patient. Answer: 1, 2, 3, 5 Explanation: 1. Actions to help this patient achieve comfort include raising the head of the bed. 2. Actions to help this patient achieve comfort include applying bed pads over the linens. 3. Actions to help this patient achieve comfort include gently massaging the extremities. 4. Reducing the amount of pain medication can increase this patient's level of pain. 5. Actions to help this patient achieve comfort include using a draw sheet when turning. Page Ref: 117 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

41 ..

42) A patient with a terminal illness is experiencing severe nausea and vomiting. Which medication should the nurse consider appropriate for the patient at this time? Select all that apply. 1. Furosemide (Lasix) 2. Ondansetron (Zofran) 3. Meperidine (Demerol) 4. Morphine sulfate (Morphine) 5. Prochlorperazine (Compazine) Answer: 2, 5 Explanation: 1. Furosemide (Lasix) is a diuretic. 2. Nausea, with or without vomiting, is a common problem in dying patients. If the patient is conscious and complains of nausea, antiemetics such as prochlorperazine (Compazine) or ondansetron (Zofran) should be administered. 3. Meperidine (Demerol) is an analgesic that can metabolize into products that could lead to seizure activity. 4. Morphine sulfate (Morphine) is an analgesic, which could be causing this patient's nausea and vomiting. 5. Nausea, with or without vomiting, is a common problem in dying patients. If the patient is conscious and complains of nausea, antiemetics such as prochlorperazine (Compazine) or ondansetron (Zofran) should be administered. Page Ref: 118 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.6. Elicit expectations of patient and family for relief of pain, discomfort, or suffering | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Quality & Safety; Knowledge; Current best practices | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

42 ..

43) During a home visit, the nurse determines that a patient whose spouse died 10 months ago is demonstrating signs of grief resolution. What did the nurse assess to come to this conclusion? Select all that apply. 1. Not living in the past 2. Breaking ties with the lost person 3. Asking for help to end the pain of the loss 4. Experiencing waves of sadness when looking at a picture 5. Wishing that death had occurred at the same time the spouse died Answer: 1, 2, 4 Explanation: 1. Evidence that grief is resolving includes not living in the past. 2. Evidence that grief is resolving includes breaking ties with the lost person. 3. Asking for help to end the pain of the loss indicates that grief resolution is not occurring. 4. Evidence that grief is resolving includes experiencing waves of sadness when looking at a picture. 5. Wishing for death at the same time that the spouse died indicates that grief resolution is not occurring. Page Ref: 123 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5.3 Outline the legal, ethical, and physiologic issues encountered when caring for the dying patient. MNL Learning Outcome: 3. Utilize the nursing process in the care of the patient receiving palliative care and care at the end-of-life.

43 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 6 Nursing Care of Patients with Problems of Substance Abuse 1) A patient is concerned about becoming an alcoholic since both parents abuse alcohol. How should the nurse respond to the patient? 1. "There are studies that support a genetic link for developing alcoholism." 2. "Why are you concerned about becoming an alcoholic?" 3. "You will likely become an alcoholic." 4. "Don't worry about that." Answer: 1 Explanation: 1. Genetic studies have been performed that suggest heredity plays a role in the development of alcoholism. The nurse should respond by saying that there are studies that support this link. 2. The nurse should not question the patient's request for information about becoming an alcoholic. 3. Although the patient does have an increased risk, the patient should not be told alcoholism is a foregone conclusion. 4. Telling the patient not to worry about becoming an alcoholic is an inappropriate response. Page Ref: 128 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

1 ..

2) The mother of a patient admitted with alcohol abuse tells the nurse that alcohol is not consumed at home and the patient is adopted. What should the nurse suspect about the patient? 1. The patient's biological parents might have abused alcohol. 2. The patient spent time drinking with friends. 3. Consuming alcohol is a symptom of stress. 4. Alcoholism is a learned behavior. Answer: 1 Explanation: 1. Genetic studies have been performed that suggest heredity plays a role in the development of alcoholism. Since the patient was adopted, the patient's biological parents may have abused alcohol. 2. There is not enough information to support that the patient is spending time drinking with friends. 3. There is not enough information to support that the patient is consuming alcohol as a symptom of stress. 4. There is not enough evidence to support this patient's alcohol use as being a learned behavior. Page Ref: 128 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

2 ..

3) A patient reports having a glass of wine every evening at home after work to "unwind" and cannot continue with the day until the wine is consumed. In which way is this patient using alcohol? 1. Cope with day-to-day problems 2. Deal with difficulty expressing emotions 3. Express a genetic need for alcohol 4. Socialize with others Answer: 1 Explanation: 1. The use of a substance as a form of self-medication to cope with day-to-day problems can become a habit. Over time, it can become an addiction. 2. There is no information to suggest that the patient is having difficulty expressing emotions. 3. There is no information to suggest that the patient has a genetic need for alcohol. 4. The patient is drinking at home after work, so there is no information to support the patient is using alcohol to socialize with others. Page Ref: 129 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

3 ..

4) While analyzing data collected during an assessment, the nurse realizes that a patient's risk for alcohol abuse is low. What information did the nurse use to come to this conclusion? 1. The patient is Asian American. 2. The patient is diagnosed with type 2 diabetes. 3. The patient has two children. 4. The patient is employed as an accountant. Answer: 1 Explanation: 1. Sociocultural factors often influence individuals' decisions regarding substance use. Asian Americans report the lowest prevalence of family history of alcoholism because of a deficiency of aldehyde dehydrogenase, which upon alcohol consumption results in toxic symptoms characterized by vomiting, flushing, and tachycardia. This is the assessment finding that would indicate that a patient's risk for alcohol abuse is low. 2. There is no information to support the concept that an individual with type 2 diabetes would avoid alcohol. 3. There is no information to support the concept that an individual with 2 children would avoid alcohol. 4. There is no information to support the concept that an individual employed as an accountant would avoid alcohol. Page Ref: 129-130 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

4 ..

5) The nurse is concerned about potential substance abuse by a coworker. What behavior should be further investigated? 1. The coworker frequently wastes medications. 2. The coworker frequently requests the largest patient care assignment for the shift. 3. The coworker prefers not to be the "medication nurse" on the shift. 4. The coworker declines to take scheduled breaks. Answer: 1 Explanation: 1. Excessive medication wasting could be a sign of using or diverting drugs. 2. Requesting a large patient care assignment would not be a characteristic of a nurse who is abusing substances. The nurse who is unable or unwilling to manage a patient care assignment could be a substance abuser. 3. Requesting not to be the medication nurse would reduce access to potentially abusive substances. 4. Taking frequent or lengthy breaks might signal substance abuse. Declining scheduled breaks is not characteristic of a substance abuser. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

5 ..

6) A nurse consistently who wears long-sleeved clothing despite the temperature being in the 90s and the air humid becomes defensive and avoids others when asked about the uniform being worn. What does the nurse's behavior suggest? 1. Substance abuse 2. A long-standing illness 3. Introverted behavior 4. Low self-esteem Answer: 1 Explanation: 1. Signs of drug use include wearing long sleeves in hot weather to cover up arms. Defensive behavior and isolation are also signs of substance abuse. 2. There is not enough information to support the idea that the nurse has a long-standing illness. 3. There is also not enough information to support the idea that the nurse routinely engages in introverted behavior. 4. There is not enough information to support the idea that the nurse has low self-esteem. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

6 ..

7) The manager is concerned that one staff nurse is demonstrating signs of substance abuse. Which behavior did the manager observe in the staff nurse? Select all that apply. 1. Calling for days off or illness before scheduled days off. 2. Using the bathroom frequently. 3. Excessive use of mouthwash. 4. Volunteering to transfer a patient to the intensive care unit. 5. Following up with nursing assistants on patient care needs. Answer: 1, 2, 3 Explanation: 1. Nurses experience many pressures in the workplace and have easy access to drugs, a temptation that may result in greater vulnerability for substance abuse and dependence. There are many observable warning signs of potential abuse, including calling for days off before scheduled days off. 2. Nurses experience many pressures in the workplace and have easy access to drugs, a temptation that may result in greater vulnerability for substance abuse and dependence. There are many observable warning signs of potential abuse, including frequent use of the bathroom. 3. Nurses experience many pressures in the workplace and have easy access to drugs, a temptation that may result in greater vulnerability for substance abuse and dependence. There are many observable warning signs of potential abuse, including excessive use of mouthwash. 4. Volunteering to transfer a patient to the intensive care unit is not an indication of substance abuse. 5. Following up with nursing assistants on patient care needs is not an indication of substance abuse. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

7 ..

8) The nurse is concerned that a colleague is experiencing depression from substance abuse. What does the nurse observe to make this assumption? 1. The colleague leaves the unit and cannot be located for long periods of time. 2. The colleague uses the visitor bathroom instead of employee bathroom. 3. The colleague often eats lunch away from the hospital. 4. The colleague complains of frequent headaches at work. Answer: 1 Explanation: 1. Leaving the unit and not being located for long periods of time indicate depression associated with substance abuse. 2. Using the visitor bathroom instead of employee bathroom is not necessarily an indication that the nurse is experiencing depression because of substance abuse. 3. Eating lunch away from the hospital is not an indication that the colleague is experiencing depression from substance abuse. 4. Complaining of a headache is not necessarily an indication that the colleague is experiencing depression from substance abuse. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

8 ..

9) A patient recovering from outpatient surgery reports frustration and excruciating pain and wants stronger pain medication immediately. What should this patient's behavior suggest to the nurse? 1. The patient could have a substance abuse problem. 2. There is a surgical wound problem. 3. The patient was not given strong enough postoperative pain medication. 4. The patient is under stress to return to work. Answer: 1 Explanation: 1. People who abuse substances often have a low tolerance for frustration and pain. Since the patient had surgery the day before and reports frustration and excruciating pain and demands more pain medication, this could indicate that the patient has a substance abuse problem. 2. There is no evidence that there is a problem with the surgical wound. 3. There is not enough information to determine whether the patient was not given strong enough postoperative pain medication. 4. There is not enough information to determine whether the patient is under stress to return to work. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

9 ..

10) A patient complaining of back pain requests several refills on any prescription since the medication is taken more frequently than prescribed. What should this information suggest to the nurse? 1. The patient has lost control over the consumption of the pain medication. 2. The patient is impulsive. 3. The patient uses the pain medication to fit in with a peer group. 4. The patient uses the pain medication to overcome low self-esteem. Answer: 1 Explanation: 1. Addictive behavior associated with substance use is characterized by loss of control over consumption. The patient states taking the medication more frequently than prescribed, which could indicate a loss of control. 2. There is no evidence that the patient is being impulsive. 3. There is no evidence that the patient is using the pain medication to fit in with a peer group. 4. There is no evidence that the patient is using the pain medication to overcome low selfesteem. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

10 ..

11) A patient receives a gunshot wound while attempting to rob a convenience store. For which health problem should this patient be assessed? 1. Drug and alcohol abuse 2. Cardiovascular disease 3. Respiratory disease 4. Mental health disorder Answer: 1 Explanation: 1. Because drug users are often rebellious against social norms and engage in risky behaviors such as stealing, the nurse should assess the patient for drug and alcohol abuse. 2. Cardiovascular disease is not usually caused by engagement in risk-taking behavior. 3. Respiratory disease is not usually caused by engagement in risk-taking behavior. 4. The patient may or may not have a mental health disorder. This type of disorder might be assessed while assessing for drug and alcohol abuse. Page Ref: 130 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

11 ..

12) A patient reports becoming very angry and abusive to friends and family when unable to obtain an illegal substance. How should the nurse respond to this patient? 1. "Have you considered seeking treatment for this behavior?" 2. "You must not have many friends left." 3. "Are you this argumentative when at work?" 4. "What does your family say about this?" Answer: 1 Explanation: 1. The patient demonstrates anger and abusive behavior when unable to obtain an illegal substance. This information should indicate that the patient has a substance abuse problem. The best response is to ask the patient if he has considered seeking treatment for this behavior. 2. The nurse should not comment on the patient's number of friends. 3. Asking if the patient is argumentative at work could incite the patient's anger and abusiveness. 4. Asking the patient about his family could incite the patient's anger. Page Ref: 130 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

12 ..

13) A patient with a history of alcohol abuse experiences consistent post-operative pain even when receiving prescribed pain medication. Which should this patient's pain experience indicate to the nurse? 1. The patient is likely cross-tolerant to the prescribed analgesic. 2. The patient has an unreported addiction to the pain medication being prescribed. 3. The patient has a history of using this medication at home. 4. The patient has a dual diagnosis relating to alcohol and drug addiction. Answer: 1 Explanation: 1. Cross-tolerance results when tolerance to one substance also results in a tolerance to another drug. The patient's heavy use of alcohol has likely resulted in a tolerance to alcohol and, by association, to the prescribed analgesic. 2. There is no evidence that the patient is addicted to the medication. 3. There is no evidence that the patient takes the medication at home. 4. There is no evidence that the patient has a dual diagnosis related to alcohol and drug addiction. Page Ref: 133 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with substance use disorder.

13 ..

14) A patient involved in a minor accident reports having used "crank" for the first time an hour ago. What manifestations can the nurse anticipate occurring with this patient? 1. Reports of insomnia and confusion 2. Demonstrates increased strength and cognition 3. Displays paranoia 4. Exhibits hallucinations Answer: 1 Explanation: 1. Crank is a form of methamphetamine. It can cause insomnia and confusion. 2. Increased strength and cognition are not associated with crank. 3. Paranoia might be seen in an individual who has been using crank for a long period of time but not after a single use. 4. Hallucinations might be seen in an individual who has been using crank for a long period of time but not after a single use. Page Ref: 136 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

14 ..

15) A patient seeks medical attention for possible sexual activity after not remembering what occurred when attending a rave. Which substance might have caused this effect in the patient? 1. Ecstasy 2. Crank 3. Marijuana 4. Alcohol Answer: 1 Explanation: 1. Ecstasy is classified as a hallucinogen and has been associated with date rape. This drug will cause the user to have thoughts and feelings similar to those in dreams. 2. Crank is a stimulant and would heighten the user's awareness. 3. Marijuana does not usually cause an individual to forget events. 4. Unless taken in high quantities over long periods of time, alcohol does not usually cause an individual to forget events. Page Ref: 137 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

15 ..

16) A patient admitted with seizures is diagnosed with a perforated nasal septum. Which substance should the nurse suspect this patient has been using? 1. Cocaine 2. Marijuana 3. Alcohol 4. Barbiturates Answer: 1 Explanation: 1. Long-term intranasal use of cocaine is associated with a perforated nasal septum. Severe overdose of cocaine can lead to a seizure disorder. 2. Seizures and perforation of the nasal septum are not associated with marijuana. 3. Seizures and perforation of the nasal septum are not associated with alcohol. 4. Seizures and perforation of the nasal septum are not associated with barbiturate abuse. Page Ref: 135 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

16 ..

17) An adolescent patient ingested barbiturates with alcohol. For which adverse effect should the nurse assess this patient? 1. Respiratory depression 2. Seizure activity 3. Signs of withdrawal 4. Signs of hallucinations Answer: 1 Explanation: 1. Barbiturates are central nervous system depressants. Barbiturates and alcohol are a lethal combination. The patient who has ingested both items is at risk for varying degrees of sedation, up to coma and death. 2. Seizure activity is not the greatest risk for this patient. 3. Signs of withdrawal are not the greatest risk for this patient. 4. Hallucinations are not the greatest risk for this patient. Page Ref: 135 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with substance use disorder.

17 ..

18) A patient overdoses on PCP. Which intervention should the nurse anticipate for this patient? 1. Administer haloperidol (Haldol) as prescribed. 2. Induce vomiting. 3. Talk the patient down. 4. Administer naloxone (Narcan) as prescribed. Answer: 1 Explanation: 1. PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The nurse should anticipate administering haloperidol (Haldol) as prescribed. 2. Inducing vomiting is not treatment for PCP overdose. 3. Talking the patient down is not recommended for PCP overdose. 4. Naloxone (Narcan) is not a treatment for PCP overdose. Page Ref: 139 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 2. Consider intraprofessional care for patients with substance use disorder.

18 ..

19) A patient has dilated pupils, respiratory rate of six per minute, and seizure activity. What should the nurse prepare to administer to this patient? 1. Naloxone (Narcan) 2. Activated charcoal 3. Ammonium chloride 4. Diazepam (Valium) Answer: 1 Explanation: 1. Dilated pupils, respiratory depression, and seizure activity are signs of heroin overdose. The nurse should prepare to administer naloxone (Narcan) to reverse the effects of central nervous system depression. 2. Activated charcoal is used for alcohol or barbiturate overdose. 3. Ammonium chloride is not identified to treat any particular overdose. 4. Diazepam (Valium) is used for LSD overdose. Page Ref: 139 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 2. Consider intraprofessional care for patients with substance use disorder.

19 ..

20) A patient with a history of chronic alcohol use is underweight and malnourished. What should the nurse expect to be prescribed to manage the patient's nutritional status? 1. Thiamine (vitamin B1) 2. Diazepam (Valium) 3. Methadone 4. Naloxone (Narcan) Answer: 1 Explanation: 1. Thiamine (vitamin B1) is necessary to prevent the complications of chronic alcoholism such as Wernicke syndrome. 2. Diazepam (Valium) is used in the acute treatment of LSD overdose. 3. Methadone is prescribed to manage heroin cravings. 4. Naloxone (Narcan) is used to treat the effects of central nervous system depression. Page Ref: 140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 2. Consider intraprofessional care for patients with substance use disorder.

20 ..

21) A patient has been using amphetamines for the last three years. Which patient statements should the nurse attribute to substance dependence? Select all that apply. 1. "I am so tired and I feel so down about everything that is happening around me." 2. "I really tried to cut down my use, but I fail miserably every time." 3. "The only thing I care about right now is getting my fix." 4. "I have to use a lot more right now to get the same high as I did before." 5. "I have a great job where I work fulltime as a mechanical engineer, so that part of my life is very fulfilling." Answer: 1, 2, 3, 4 Explanation: 1. Fatigue and depression are withdrawal symptoms associated with the use of amphetamines. 2. Behavior associated with substance dependence includes unsuccessful attempts to cut down on the use of the substance. 3. Fixation on obtaining more of the substance is characteristic of dependency. 4. Patients are more likely to develop tolerance to the drug and require greater quantities to get the same result. 5. It is unlikely that a patient with substance dependence is continuing to keep a fulltime job because the patient will usually spend a lot of time procuring and using the drug and invest less time with occupational activities. Page Ref: 136 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

21 ..

22) The nurse is preparing material for a staff development presentation on alcohol abuse in families. Which information should the nurse include that increases the risk of alcohol abuse? Select all that apply. 1. An alcoholic parent is depressed or has another psychological problem. 2. Both parents abuse alcohol and other drugs. 3. The parents' alcohol abuse is severe. 4. Family conflicts lead to aggression and violence. 5. Children of alcoholics will avoid the substance because of family exposure. Answer: 1, 2, 3 Explanation: 1. A family risk factor for alcoholism is having an alcoholic parent who is depressed or has another psychological problem. 2. A family risk factor for alcoholism is both parents abusing alcohol and other drugs. 3. A family risk factor for alcoholism is having parents whose alcohol abuse is severe. 4. A family risk factor for alcoholism is being subjected to family conflicts that lead to aggression and violence. 5. There is no evidence that children of alcoholics will avoid the substance because of family exposure. Page Ref: 129 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

22 ..

23) A patient is being treated for withdrawal symptoms. Which patient statement indicates that additional teaching about prescribed medication is required? Select all that apply. 1. "Naltrexone is an antidepressant." 2. "The Antabuse will help me with my cravings for heroin." 3. "The chlordiazepoxide is also called Librium and it can help with my anxiety." 4. "The phenobarbital will help prevent me from having another seizure." 5. "I need folic acid and other vitamin supplements because I haven't eaten well for so long." Answer: 1, 2 Explanation: 1. Naltrexone (ReVia) helps diminish cravings for alcohol and opiates. It is not an antidepressant. 2. Disulfiram (Antabuse) is given to patients to stop the breakdown of alcohol within the body and make the consequences of drinking alcohol more severe. Methadone will help block heroin cravings. 3. Chlordiazepoxide (Librium) can be used to help with anxiety and prevent seizure activity. 4. Phenobarbital can help prevent seizure activity. 5. Vitamin supplements can help the patient with alcoholism because patients with alcoholism are more likely to have developed vitamin deficiencies. Page Ref: 140 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with substance use disorder.

23 ..

24) A nurse is concerned that a newly hired colleague is exhibiting signs of a substance abuse problem. What did the nurse observe to come to this conclusion? Select all that apply. 1. The new nurse is always sucking on mints and has applied strong-smelling cologne. 2. The new nurse completes documentation and is prepared to give report at the end of the shift. 3. The new nurse has volunteered to give medications to patients. 4. The new nurse has displayed difficulty juggling his patient assignment and seems to be highly unorganized. 5. The narcotic count at the end of the shift is off; two doses of morphine sulfate are missing. Answer: 1, 3, 4, 5 Explanation: 1. Eating an excessive number of mints and wearing strong-smelling cologne can be used to mask odors of alcohol on the nurse's breath. 2. Completing documentation and being prepared to give report at the end of the shift does not indicate a substance abuse problem. 3. Offering to give medications to patients is consistent with a substance use problem. 4. Unorganized thinking and erratic behavior are consistent with a substance use problem. 5. The narcotic count is off while this nurse is working; this is consistent with a nurse who uses narcotics from the hospital supply. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

24 ..

25) The patient is exhibiting addictive behaviors and has admitted to using illegal drugs. Which patient statement is consistent with addictive behaviors? Select all that apply. 1. "I think even as a child I was much more anxious than my friends." 2. "When I was in the hospital for appendicitis, they told me they had to give me more pain medications than normal because I was still in pain." 3. "Sometimes I steal things from stores just to see if I can get away with it." 4. "I like to play it safe. When my friends were bungee jumping off the bridge, I just watched." 5. "I have always been very slow to anger." Answer: 1, 2, 3 Explanation: 1. People who are displaying addictive behaviors associated with substance use are more likely to be anxious. 2. People who are displaying addictive behaviors associated with substance use are more likely to have a low tolerance for pain. 3. People who are displaying addictive behaviors associated with substance use are more likely to participate in risky behaviors such as stealing. 4. People who are displaying addictive behaviors associated with substance use are more likely to participate in risky behaviors such as bungee jumping without regard for social norms or their own safety. 5. People who are displaying addictive behaviors associated with substance use are more likely to become angry than others who are not using substances. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

25 ..

26) The patient states, "I think I am actually addicted to nicotine." Which assessment findings are consistent with this type of addiction? Select all that apply. 1. The blood pressure is 182/86 mmHg. 2. The patient states, "Sometimes, I feel so nauseated after I smoke cigarettes." 3. The patient states, "I have never been able to stop smoking for more than two weeks at a time because the cravings get so bad." 4. An apical heart rate is 72 beats per minute. 5. A respiratory rate is 14 breaths per minute. Answer: 1, 2, 3 Explanation: 1. Nicotine use results in the release of norepinephrine and epinephrine, which produces vasoconstriction. Vasoconstriction will increase the patient's blood pressure. 2. Patients who use nicotine will find that it promotes vomiting. 3. Quitting smoking is thought to be more difficult because of dopamine release, which reinforces the craving for more. 4. Due to the effects of the norepinephrine and epinephrine, the patient's heart rate would be higher than 72 beats per minute. 5. Due to the effects of the norepinephrine and epinephrine, the patient's respiratory rate would be greater than 14 breaths per minute. Page Ref: 133-134 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

26 ..

27) The nurse reviews the long-term effects of alcohol use with a patient who has experienced chronic alcoholism for 25 years. Which patient statements indicate that additional teaching is required? Select all that apply. 1. "My yellow skin is really just caused by the thiamine deficiency." 2. "My problems with COPD weren't because I smoke; it's because I was drinking so much." 3. "I was surprised to learn that my coronary artery disease may have been worsened by my drinking." 4. "I think I would've stopped drinking a long time ago if I had known that it may have caused my impotence." 5. "My mom was an alcoholic and died from breast cancer and it may have been the result of her drinking." Answer: 1, 2 Explanation: 1. Patients who have severely damaged their livers because of alcohol abuse may be more likely to exhibit yellow skin and sclera. Jaundice is unrelated to a vitamin B 1 deficiency. 2. The patient who smokes cigarettes is more likely to develop asthma. Asthma is not necessarily associated with drinking alcohol. 3. The patient had an increased risk of developing heart problems by drinking alcohol. 4. The patient had an increased chance of developing impotence by drinking. 5. The patient's mother had an increased risk of developing breast cancer due to her alcoholism. Page Ref: 132 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

27 ..

28) A patient has been brought to the emergency department with a blood alcohol level of 0.51%. Which finding is consistent with this information? Select all that apply. 1. A sternal rub was performed with no response elicited. 2. The patient's respiratory rate is eight breaths per minute. 3. The patient's radial and pedal pulses are bounding. 4. The patient states, "I sleep for a long time, but I never feel rested when I wake up." 5. The patient states, "I really think I can drive myself home. I am fine!" Answer: 1, 2 Explanation: 1. With this blood alcohol level, the patient is likely to be in a coma. 2. The patient's respiratory rate may be very depressed. 3. The peripheral pulses are more likely to be weak and thready due to peripheral vascular collapse, which would make it difficult for them to be palpated. 4. The patient is not likely to be talking to the nurse about the quality of his sleep. 5. The patient is not likely to be talking to the nurse about his ability to drive. Page Ref: 133 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

28 ..

29) A patient with injuries from a motor vehicle crash frequently smokes ice and had smoked some as recently as two hours prior to the accident. Which assessment finding is consistent with this information? Select all that apply. 1. Apical heart rate is 112 beats per minute. 2. Supraventricular contractions are noted during electrocardiogram. 3. The patient weighs 92 pounds and is 5′5″ tall. 4. The patient is complaining of chest pain. 5. Blood pressure is 96/72 mmHg. Answer: 1, 2, 3, 4 Explanation: 1. The patient will likely exhibit tachycardia. 2. The patient will likely exhibit dysrhythmias. 3. The patient's appetite has been suppressed by the methamphetamine use and the patient will likely be thin. 4. Angina is a common complaint among people who use methamphetamines. 5. The patient's blood pressure is likely to be elevated due to the vasoconstriction that is produced by this type of drug use. Page Ref: 135-136 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

29 ..

30) The nurse suspects that a patient has a substance dependency. What observation did the nurse use to come to this conclusion? Select all that apply. 1. Presence of tolerance 2. Substance taken longer than intended 3. Spends more time in private using the substance 4. Desire to control substance use 5. Discontinues use while experiencing intrapersonal problems Answer: 1, 2, 3, 4 Explanation: 1. Substance dependence is demonstrated by tolerance to the drug. 2. Substance dependence is demonstrated by using the drug longer than intended. 3. Substance dependence is demonstrated by spending more time using the substance in private. 4. There is an unsuccessful persistent desire to cut down or control the substance. 5. Substance abuse manifestations include continued use despite intrapersonal problems. Page Ref: 127 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

30 ..

31) The nurse is caring for a patient who uses marijuana. Which observations suggest that the amount of marijuana that the patient is using is dose-related? Select all that apply. 1. Fetal CNS disturbances 2. Tachycardia 3. Asthma with long-term use 4. Diuresis 5. Hypertension Answer: 1, 2, 3 Explanation: 1. The use of cannabis during pregnancy can cause fetal CNS changes. 2. The use of cannabis can cause tachycardia. 3. With long-term use, cannabis can cause asthma. 4. Diuresis is not caused by cannabis, but is caused by the use of caffeine. 5. Hypertension is not caused by cannabis, but is found in cocaine users. Page Ref: 135 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.2 Differentiate the effects of selected addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with substance use disorder.

31 ..

32) The nurse is caring for a patient with chronic alcoholism. Which vitamin should the nurse expect this patient to be prescribed? Select all that apply. 1. Thiamine (vitamin B1) 2. Folic acid 3. Cyanocobalamin (vitamin B12) 4. Vitamin E 5. Potassium chloride Answer: 1, 2 Explanation: 1. Patients using alcohol over a long period of time will have a vitamin deficiency, especially of thiamine and folic acid. These two vitamins help prevent Wernicke encephalopathy. 2. Patients using alcohol over a long period of time will have a vitamin deficiency, especially of thiamine and folic acid. These two vitamins help prevent Wernicke encephalopathy. 3. Cyanocobalamin (vitamin B12) may be important but would be found in a multivitamin. 4. Vitamin E may be important but would be found in a multivitamin. 5. Potassium chloride is incorrect as it is a mineral/electrolyte. Page Ref: 140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; chronic disease management | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 2. Consider intraprofessional care for patients with substance use disorder.

32 ..

33) The nurse is assessing a patient with substance abuse. What question should the nurse use to obtain the most information during this assessment? Select all that apply. 1. On average, how many days a week do you drink or use drugs? 2. How often and how much do you usually use? 3. What is the greatest number of drinks you have had at any one time in the past month? 4. Do you drink beer or whiskey? 5. Did you drink beer before coming to the hospital? Answer: 1, 2, 3 Explanation: 1. Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss the use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than "Yes" or "No." 2. Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss the use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than "Yes" or "No." 3. Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss the use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than "Yes" or "No." 4. Options 4 and 5 are closed questions and require that the patient only answer "Yes" or "No." 5. Options 4 and 5 are closed questions and require that the patient only answer "Yes" or "No." Page Ref: 141 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with substance use disorder.

33 ..

34) A nurse has been convicted of driving while under the influence. What regulatory body will determine the status of the nurse's license? 1. State board of nursing 2. Employee assistance program 3. State court system 4. American Nurses Association Answer: 1 Explanation: 1. Because the nurse has been convicted, the board in the state of the nurse's residence will investigate and take action including censure, probation, or suspension of the nursing license. 2. An employee assistance program may be involved but will not investigate the conviction. 3. With the conviction, the court system has taken action and would be in the county, not the state. 4. The American Nurses Association will not be involved. Page Ref: 130 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

34 ..

35) The manager suspects that a nurse is experiencing role strain and is at risk for developing substance abuse. What did the manager observe to come to this conclusion about the nurse? Select all that apply. 1. Frequently late to work 2. Incomplete charting 3. Errors in patient care judgment 4. Erratic behavior 5. Mood swings Answer: 1, 2, 3, 4 Explanation: 1. Warning signs of role strain that could indicate substance abuse include frequent tardiness or absenteeism, especially before and after scheduled days off. 2. Warning signs of role strain that could indicate substance abuse include shoddy charting. 3. Warning signs of role strain that could indicate substance abuse include patient care judgment errors. 4. Warning signs of role strain that could indicate substance abuse include unorganized erratic behavior. 5. Mood swings are a characteristic of depression. Page Ref: 130 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: II.B.6. Initiate requests for help when appropriate to situation | AACN Essentials Competencies: VIII.12. Act to prevent unsafe, illegal or unethical care practices | NLN Competencies: Personal and Professional Development; Ethics Comportment Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

35 ..

36) The nurse identifies the problem of imbalanced nutrition due to insufficient intake for a patient hospitalized for substance abuse. What intervention should the nurse identify as appropriate for this patient? Select all that apply. 1. Monitor the CBC and liver enzymes. 2. Collaborate with the dietician. 3. Administer vitamins and diet supplements. 4. Provide high fat, high carbohydrate diet. 5. Restrict fluid intake to 1500 mL per day. Answer: 1, 2, 3 Explanation: 1. Laboratory values should be monitored to evaluate the extent of malnourishment. 2. The dietician can help with meal planning for adequate nutrition and realistic weight gain. 3. Vitamins and dietary supplements may be prescribed to prevent complications from chronic alcoholism such as Wernicke syndrome. 4. A high fat, high carbohydrate diet is not appropriate as the patient needs balanced nutritional intake to provide for calories, proteins, vitamins, minerals, and carbohydrates. 5. The fluid intake will not be restricted as there is no physiological reason unless the patient has a co-morbidity. Page Ref: 144 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with substance use disorder.

36 ..

37) The nurse is determining a patient's degree of dependence on a substance. Which screening tool should the nurse use to help with this assessment? Select all that apply. 1. Michigan Alcohol Screening Test 2. CAGE questionnaire 3. Brief Drug Abuse Screening Test 4. Clinical Institute Withdrawal Assessment of Alcohol-Revised 5. Clinical Opiate Withdrawal Scale Answer: 1, 2, 3 Explanation: 1. The Michigan Alcohol Screening Test, CAGE questionnaire, and Brief Drug Abuse Screening Test provide a nonjudgmental, brief, and easy method to determine patterns of substance abuse behaviors. 2. The Michigan Alcohol Screening Test, CAGE questionnaire, and Brief Drug Abuse Screening Test provide a nonjudgmental, brief, and easy method to determine patterns of substance abuse behaviors. 3. The Michigan Alcohol Screening Test, CAGE questionnaire, and Brief Drug Abuse Screening Test provide a nonjudgmental, brief, and easy method to determine patterns of substance abuse behaviors. 4. The Clinical Institute Withdrawal Assessment of Alcohol, Revised is an assessment tool for withdrawal from alcohol and drugs and can indicate the need for pharmacologic treatment to manage withdrawal. 5. The Clinical Opiate Withdrawal Scale is an assessment tool for withdrawal from alcohol and drugs and can indicate the need for pharmacologic treatment to manage withdrawal. Page Ref: 142 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with substance use disorder.

37 ..

38) The nurse is assessing a patient for alcohol abuse. On which mental health problems should the nurse focus during this assessment? Select all that apply. 1. Psychosis 2. Depression 3. Malnutrition 4. Alzheimer disease 5. Cerebrovascular accident Answer: 1, 2 Explanation: 1. The most commonly co-occurring mental disorders in adults are alcohol abuse or alcohol dependence with depression or psychoses. 2. The most commonly co-occurring mental disorders in adults are alcohol abuse or alcohol dependence with depression or psychoses. 3. Malnutrition is not a mental health problem. 4. Alzheimer disease is not associated with alcohol abuse. It is not considered a mental health problem. 5. Cerebrovascular accident is a cardiac disorder that affects blood flow to the brain. The patient may demonstrate alterations in behavior and consciousness; however, this is not a mental health problem. Page Ref: 128 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

38 ..

39) During an assessment a patient with multiple substance addictions asks why the need for drugs and alcohol is so great. What should the nurse include when responding to this patient? Select all that apply. 1. "Substance abuse is a sign of weakness and boredom with life." 2. "It becomes a habit of self-medication, used to cope with daily problems." 3. "There is a human tendency to seek pleasure and avoid stress and pain." 4. "It really depends upon genetic makeup and if your parents used drugs." 5. "One substance in the brain, dopamine, is responsible for drug-seeking behavior." Answer: 2, 3, 5 Explanation: 1. There is no evidence that substance abuse is a sign of weakness and boredom with life. 2. The habit of using a substance becomes a form of self-medication to cope with day-to-day problems. 3. The human tendency to seek pleasure and avoid stress and pain is partially responsible for substance abuse. 4. Genetic makeup and biological factors do contribute to substance abuse behaviors; however, there are other explanations. 5. Dopamine has been identified as the primary neurotransmitter responsible for sustaining the addictive quality of drugs and for increasing drug-seeking behavior. Page Ref: 127, 129 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6.1 Outline the pathophysiology, manifestations, and complications of substance abuse; the risk factors for substance abuse; and characteristics of individuals who abuse substances including nurses. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with substance use disorder.

39 ..

40) The nurse uses the CAGE questionnaire and B-DAST screening tool to assess an adolescent experiencing panic and agitation. Which substance is the nurse most likely planning to assess in this patient? Select all that apply. 1. PCP 2. LSD 3. Crack 4. Heroin 5. Alcohol Answer: 1, 2, 5 Explanation: 1. A manifestation of PCP overdose is agitation. 2. A manifestation of LSD overdose is panic. 3. The patient is not demonstrating evidence of crack overdose. 4. The patient is not demonstrating evidence of heroin overdose. 5. Alcohol is the most commonly used and abused legal substance in the United States. Page Ref: 139 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Chemical and Other Dependencies/Substance Use Disorder Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6.3 Describe the interprofessional care, nursing care, and transitions of care for patients who abuse substances. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with substance use disorder.

40 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 7 Nursing Care of Patients Experiencing Disasters 1) A school bus transporting approximately 60 students crashed on the side of the road. Which classification should the nurse use to describe the situation? 1. Multiple-casualty incident 2. Natural disaster 3. Human-generated disaster 4. Mass-casualty incident Answer: 1 Explanation: 1. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. 2. Natural disasters are caused by acts of nature or emerging diseases. 3. Human-generated disasters are either accidental or intentional. 4. A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. Page Ref: 160 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1 Explain the difference between an emergency and a disaster. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

1 ..

2) A patient received injuries during an earthquake. Which type of incident should the nurse identify as causing this patient's injuries? 1. Natural disaster 2. Human-generated disaster 3. Emergency 4. Multiple-casualty incident Answer: 1 Explanation: 1. Natural disasters are caused by acts of nature and may be predictable, through advanced meteorological technologies, or unexpected. An earthquake is an example of a natural disaster. 2. A human-generated disaster can be either accidental or intentional. An example of a humangenerated disaster is war or biological warfare. 3. An emergency can generally be handled within the emergency management system. 4. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Page Ref: 160 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1 Explain the difference between an emergency and a disaster. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

2 ..

3) A small commuter plane crashed into a shopping mall, injuring approximately 500 people. Which classification of incident should the nurse use when determining the care needed for these victims? 1. Mass-casualty incident 2. Multiple-casualty incident 3. Accidental natural disaster 4. Intentional human-generated disaster Answer: 1 Explanation: 1. A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. 2. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. 3. Natural disasters are caused by acts of nature or emerging diseases. 4. An intentional human-generated disaster is done with specific intent. Page Ref: 160 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1 Explain the difference between an emergency and a disaster. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

3 ..

4) A derailed train caused a hazardous spill with noxious gasses released into the environment. Local and surrounding fire control and Hazmat teams are controlling the event. For which type of situation should the nurse prepare? 1. Emergency 2. Disaster 3. Human-generated accidental disaster 4. Intentional emergency Answer: 1 Explanation: 1. The difference between an emergency and a disaster is that an emergency can be handled by the management systems in place. Because the fire and Hazmat teams handled the event, it is considered an emergency. 2. A disaster would overwhelm the management systems in place. 3. Because the management systems in place were able to handle the event, this is not a disaster. 4. Intentional emergency is not a classification used for these types of event. Page Ref: 160 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.1 Explain the difference between an emergency and a disaster. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

4 ..

5) The nurse is caring for patients when a dirty bomb detonates at a nearby shopping mall. Which types of injuries should the nurse expect to see in the victims? 1. Radiation sickness 2. Fractured limbs and spinal injury 3. Thermal burns 4. Overexertion and exhaustion Answer: 1 Explanation: 1. Radiation sickness commonly occurs with a radiological dispersion bomb or dirty bomb blast. 2. Fractured limbs and spinal injury can occur with blunt trauma. 3. Thermal burns occur with nuclear detonation. 4. Overexertion and exhaustion occur in other types of injuries, such as snowstorm-related injuries. Page Ref: 164 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.3 Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 3. Differentiate between the types of terrorism and associated injuries.

5 ..

6) A patient with injuries from an explosion at a nuclear power plant is confused and keeps repeating "I'm on fire." What does this information indicate to the nurse? 1. The patient may not recover. 2. The patient's clothing is burning his skin. 3. There is gastrointestinal system involvement and the patient will survive if he receives fluids. 4. There is bone marrow damage, and the patient needs oxygen for the confusion. Answer: 1 Explanation: 1. With acute radiation exposure, blood vessel and nerve cells are damaged and the patient is incapacitated and experiences cardiovascular collapse, confusion, and even an "on fire" sensation throughout the body; symptoms this severe generally do not permit survival. 2. The patient's clothing would be burning his skin if he had experienced a chemical injury. 3. Evidence of gastrointestinal system involvement would be nausea, loss of appetite, diarrhea, and malaise. 4. Evidence of bone marrow damage would be nausea, fatigue, malaise, clotting disorders, and hemorrhage. Page Ref: 165 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

6 ..

7) A patient is brought into the emergency department complaining of blindness after an explosion at an atomic power plant. What should the nurse explain to this patient? 1. "The effects of the blast will disappear with time." 2. "I'm afraid the blast has caused permanent blindness." 3. "I will contact Social Services so that resources can be identified to help you with your disability." 4. "There is a variety of resources available for those who are unable to see." Answer: 1 Explanation: 1. The bright flash of a nuclear detonation can cause temporary blindness, but vision returns. The patient may need assistance until vision is restored. The nurse should explain that the effects of the blast will disappear with time. 2. The nurse should not say that the patient is permanently blind. 3. The nurse does not need to contact social services at this time for the patient's temporary blindness. 4. Suggesting resources for the vision-impaired is premature, as the blindness is temporary. Page Ref: 165 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

7 ..

8) The nurse is caring for a patient who experienced a blast injury to the eye. Which intervention would be appropriate? 1. Flush the eye with eyewash. 2. Encourage the patient to rub the eye to get out specks of dust. 3. Apply a warm compress to the eye. 4. Remove debris lodged in the eye. Answer: 1 Explanation: 1. The nurse should flush the patient's eye with eyewash. 2. The patient should be cautioned not to rub the eye that has specks of dust or debris in it. 3. A cool compress and not a warm compress should be applied to the eye. 4. Debris lodged in the eye should be stabilized and not removed without medical attention. Page Ref: 164 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 3. Differentiate between the types of terrorism and associated injuries.

8 ..

9) The nurse is admitting the second patient in 2 days who is experiencing malaise, high fever, and headache. Both patients attended a local air show the previous weekend. What should the nurse do? 1. Discuss the need to contact public health authorities regarding the similarity of the cases. 2. Plan to place the patients in the same room. 3. Ask the patients for permission to talk with family members regarding other symptoms. 4. Assess the patients for what foods they ate while at the air show. Answer: 1 Explanation: 1. The nurse should be alert to illness patterns that could indicate an unusual infectious disease outbreak. Indicators of a biologic agent release include an increased disease incidence among people who attended the same event. The presence of one or more indicators should be reported to public health authorities to determine the source of the infectious disease and prevent further exposure. 2. Placing the patients in the same room may or may not be appropriate. 3. The family members of the patients do not need to be assessed at this time. 4. The foods ingested during the air show may not provide enough information about the patients' exposure. Page Ref: 164 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the healthcare team | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Communicate effectively with different individuals (team members, other care providers, patients, families, etc.) so as to minimize risks associated with handoffs among providers and across transitions in care. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3 Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 3. Differentiate between the types of terrorism and associated injuries.

9 ..

10) An individual with injuries sustained in a natural gas explosion is unable to respond to questions and keeps repeating "I can't hear." For what should the nurse assess this patient? 1. Tympanic membrane rupture 2. Air embolism 3. Oxygen saturation level 4. Confusion Answer: 1 Explanation: 1. After a blast injury, damage to the ear can include tympanic membrane rupture or damage to the cochlea. As the patient is expressing difficulty hearing, the tympanic membrane should be assessed. 2. An air embolism would impact the patient's respiratory status. 3. There is no evidence to suggest the patient's oxygen saturation level is impaired. 4. There is no evidence of confusion. Page Ref: 165 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

10 ..

11) A victim of a chemical plant explosion is unconscious and brought into the emergency department. For what should the nurse assess this patient? 1. Central nervous system injury 2. Respiratory system injury 3. Pulmonary emboli 4. Radiation sickness Answer: 1 Explanation: 1. The patient who is unconscious after an explosion should be further assessed for concussion, closed and open brain injury, stroke, spinal cord injury, or air embolism-induced injury. 2. Respiratory system injuries would manifest as hemothorax, pneumothorax, or pulmonary contusion and hemorrhage. 3. Pulmonary emboli can occur with respiratory or cardiac system injuries. 4. Evidence of radiation sickness includes nausea, diarrhea, and malaise. Page Ref: 165 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

11 ..

12) Victims of a school bus crash are being triaged at the accident site. What principle should be followed when implementing reverse triage? Select all that apply. 1. Used when there is a mass casualty event with more than 100 victims. 2. Works on the principle of the greatest good for the greatest number. 3. Categorizes victims needing the most support and emergency care as red, so they can be treated first. 4. Color-codes victims most likely to survive as black to be treated first. 5. Works on the principle of the greatest good for the most critically ill. Answer: 1, 2 Explanation: 1. This is a principle of reverse triage. 2. This is a principle of reverse triage. 3. This is a principle of basic triage. 4. Victims who are color-coded black are not likely to survive. 5. Basic triage works on the principle of the greatest good for the most critically ill. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

12 ..

13) After a serious highway accident involving 22 vehicles, ambulatory victims with minor injuries are transported home. For which reason were these victims triaged first? 1. Do the greatest good for the greatest number of people. 2. Remove them so they do not see the critically injured victims. 3. Secure the site in case the vehicles become overheated and ignite. 4. Improve traffic conditions to clear the accident site quickly. Answer: 1 Explanation: 1. Reverse triage works on the principle of the greatest good for the greatest number of people. 2. Because these victims are ambulatory, with minor injuries, they can be transported home and away from the scene of the accident. The purpose of reverse triage is not to prevent them from seeing critically injured victims. 3. The purpose of reverse triage is not to secure the accident site. 4. The purpose of reverse triage is not to improve traffic conditions. Page Ref: 169 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

13 ..

14) At the site of a collapsed building, some victims are walking away from the building, while others are lying on the ground around the perimeter. What should be done first when implementing reverse triage? 1. Identify one safe location for all ambulatory victims to be assessed and observed. 2. Systematically assess each victim lying on the ground and assign a color. 3. Enter the building to locate other victims who might not have been able to leave before the collapse. 4. Transfer the victims on the ground to stretchers and send them to the local emergency department. Answer: 1 Explanation: 1. Reverse triage works on the principle of the greatest good for the greatest number of people. One safe location should be identified for all ambulatory victims to be assessed and observed. 2. Systematically assessing the victims on the ground and assigning colors is not following the principle of reverse triage. 3. Entering the building to locate other victims would be done after all victims who are ambulatory or on the ground are assessed and treated. 4. Transferring victims on the ground to stretchers and sending them to local emergency departments is done after systematic assessment. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

14 ..

15) A victim of a plane crash exits the plane and tells emergency personnel that a family member is inside and unable to walk. Which action should be taken? 1. Assist with clearing all the victims who are ambulatory first, then locate the trapped victim. 2. Enter the plane to locate the trapped victim. 3. Tell the victim that the family member will be fine and will be removed from the plane as soon as possible. 4. Tell the victim to go back inside and try to get the family member to walk. Answer: 1 Explanation: 1. If following the principles of reverse triage, emergency personnel should assist with clearing all victims who are ambulatory first and then locate the trapped victim. 2. The emergency provider should not enter the plane to locate the trapped victim first. 3. The emergency provider should not tell the victim that the family member will be fine because there is no way of knowing the extent of injuries. 4. The emergency provider should not tell the victim to go back inside the wreckage and get the family member to walk. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

15 ..

16) The nurse arrives at the site of a bombed building. When preparing to triage victims, in which zone should the nurse conduct decontamination? 1. Warm 2. Hot 3. Cold 4. Green Answer: 1 Explanation: 1. The warm zone, or control zone, is adjacent to the hot zone. This is where the decontamination of victims or triage and emergency treatment takes place. 2. The site where a weapon was released or where contamination occurred is called the hot zone. It is considered to be contaminated, and only those persons in the appropriate personal protective equipment may enter this zone. 3. The cold zone is considered the safe zone. 4. There is no green zone when working with decontamination. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

16 ..

17) Emergency response personnel are wearing gowns, gloves, goggles, and masks. In which decontamination zone are these personnel most likely working? 1. Hot 2. Warm 3. Cold 4. Yellow Answer: 1 Explanation: 1. The site of the disaster where a weapon was released or where contamination occurred is called the hot zone. It is considered contaminated, and only those persons in the appropriate personal protective equipment may enter this zone. This equipment includes gloves, masks, goggles, gowns, and biologic disposal bags. 2. The warm zone is adjacent to the hot zone. This area is where decontamination of victims or triage and emergency treatment take place. The level of personal protective equipment required is based on the dynamic risk assessment of the threat and the agent involved. 3. The cold zone is considered the safe zone. It is adjacent to the warm zone and is the area where a more in-depth triage of victims would occur. Personal protective equipment needs are minimal in this zone. 4. There is no yellow decontamination zone. Page Ref: 169 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

17 ..

18) Several victims of a suspected biologic attack are brought into the emergency department. Which type of personal protective equipment should be provided to these victims? 1. Mask 2. Gown 3. Gloves 4. Goggles Answer: 1 Explanation: 1. In the event of a biologic attack, victims should be isolated from others or have some device to cover the nose and mouth to prevent the transmission of the organism. The victims should be wearing a mask. 2. A gown would not be indicated at this time. 3. Gloves would not be indicated at this time. 4. Goggles would not be indicated at this time. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

18 ..

19) At the site of a building collapse, ambulances are nearby and a shelter has been set up with carts, chairs, tables, and refreshments for the victims. Within which decontamination zone are the victims being assessed? 1. Cold 2. Warm 3. Control 4. Hot Answer: 1 Explanation: 1. The cold zone is considered the safe zone. It is adjacent to the warm zone and is the area where a more in-depth triage of victims would occur. Survivors may find shelter in this area, and the command and control vehicles as well as emergency transport vehicles would be found here. 2. The warm zone is adjacent to the hot zone. This is where decontamination of victims or triage and emergency treatment take place. 3. Another name for the warm zone is the control zone. This is where decontamination of victims or triage and emergency treatment take place. 4. The site where a weapon was released or contamination occurred is called the hot zone. It is considered to be contaminated, and only those persons in the appropriate personal protective equipment may enter this zone. Page Ref: 169 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

19 ..

20) The nurse is reviewing the stages and phases of a disaster as part of a continuing education program in the hospital. In which order should the nurse list the stages of disaster management? 1. Preparedness, mitigation, response, recovery, and evaluation 2. Mitigation, preparedness, response, recovery, and evaluation 3. Mitigation, response, recovery, preparedness, and evaluation 4. Response, mitigation, evaluation, recovery, and preparedness Answer: 1 Explanation: 1. Disaster management is a cyclical process comprising preparedness, mitigation, response, recovery, and evaluation. 2. The five basic stages of disaster management do not follow this sequence. 3. The five basic stages of disaster management do not follow this sequence. 4. The five basic stages of disaster management do not follow this sequence. Page Ref: 161 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

20 ..

21) The nurse is planning a program to address disaster mitigation activities in the community. What should the nurse consult when preparing this program? 1. Community disaster preparedness plan 2. Hospital administrators 3. Physicians with practices in the community 4. Schools and day care centers Answer: 1 Explanation: 1. One role of the nurse in disaster planning is to prepare self, families, friends, and communities for disasters in conjunction with the local disaster preparedness plan. 2. The nurse does not need to consult hospital administrators when planning this program. 3. The nurse does not need to consult physicians when planning this program. 4. The nurse does not need to consult schools and day care centers when planning this program. Page Ref: 171 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

21 ..

22) The nurse is presenting a program to residents of a local senior citizen housing facility about preparations in the event of a disaster. What should the nurse instruct the participants to do regarding essential preparations? 1. Have a list of medications, emergency contact numbers, and necessary survival items readily available. 2. Turn off all electrical devices before leaving the premises. 3. Pack enough nonperishable food items to last for several days. 4. Bring recreational items such as puzzles and card games for entertainment. Answer: 1 Explanation: 1. The nurse should instruct older adults to prepare a current list of medications, doses, and times of administration. The names and phone numbers of significant persons, relatives, those with power of attorney, healthcare providers, and any others to be notified in case of emergency should also be kept in an easily accessible place. Additionally, the following materials should be considered essential should evacuation to a shelter be necessary: eyeglasses and eyeglass prescriptions, style and serial numbers of medical devices such as pacemakers, healthcare policies and numbers, identification, list of allergies, blood type, checkbook, credit cards, insurance agent's name and number, driver's license, 72-hour supply of medications, dentures, list of special dietary needs, sturdy shoes, warm clothing, blankets, incontinence briefs, prostheses, hearing aids, hearing aid batteries, extra wheelchair batteries, oxygen, and other assistive devices. 2. The residents of a senior facility do not need to be concerned with turning off electrical devices. 3. The residents of a senior facility do not need to be concerned with packing food items. 4. Recreational items are not considered survival items. Page Ref: 172 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

22 ..

23) A group of nurses are attending a meeting to discuss the outcome and results of care provided to victims of a recent building collapse. In which phase of the disaster planning process are the nurses participating? 1. Evaluation 2. Recovery 3. Restoration 4. Response Answer: 1 Explanation: 1. The final stage of recovery is evaluation, which is also an activity in the preparation and planning aspects of the nondisaster stage. Future-oriented activities take place to prevent subsequent disasters or to minimize their effects. Nurses participate by discussing suggestions to improve the response time to victims or ways to improve treatment. 2. The recovery aspect of disaster response, also called reconstruction, involves rebuilding and returning to some semblance of normalcy. 3. Restoration includes rebuilding, replacing lost or damaged property, returning to school and work, and continuing life without those who were killed in the disaster. 4. The response phase involves the immediate response to the disaster. Page Ref: 163 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

23 ..

24) The nurse is planning to attend a program to learn how to respond to mass casualty incidents. Which core competencies should the nurse expect to learn during this program? Select all that apply. 1. Risk reduction, disease prevention, and health promotion 2. Nursing process 3. Policy development and planning 4. Community care 5. Ethical and legal practice Answer: 1, 3, 4, 5 Explanation: 1. Disaster nursing competencies include risk reduction, disease prevention, and health promotion. 2. The nursing process is not considered a core competency for disaster nursing. 3. Disaster nursing competencies include policy development and planning. 4. Disaster nursing competencies include community care. 5. Disaster nursing competencies include ethical and legal practice. Page Ref: 160 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 7.1 Explain the difference between an emergency and a disaster. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

24 ..

25) A subway derailed injuring approximately 250 passengers. For which type of situation should the emergency department manager prepare? 1. Natural disaster 2. Multiple-casualty incident 3. Mass-casualty incident 4. Accidental disaster Answer: 3 Explanation: 1. Natural disasters are caused by acts of nature or emerging diseases. 2. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. 3. A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. 4. An accidental disaster is human-generated. Page Ref: 160 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.1 Explain the difference between an emergency and a disaster. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

25 ..

26) An organization has been alerted to a possible illness associated with the tainting of a popular over-the-counter pain reliever. For which type of event should the facility plan? 1. Nonconventional terrorist attack 2. Conventional terrorist attack 3. Accidental disaster 4. Natural disaster Answer: 1 Explanation: 1. Nonconventional terrorism uses chemical, biological, and nuclear means to release a toxin, contaminate a food source, or contaminate some other product. 2. This would not be classified as a conventional type of terrorist attack. 3. This would not be classified as an accidental disaster. 4. This would not be classified as a natural disaster. Page Ref: 163 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.3 Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 3. Differentiate between the types of terrorism and associated injuries.

26 ..

27) An unusually high number of patients are coming into the emergency department with complaints of nausea, vomiting, and severe headache. What should be done with this information? 1. No further action is needed at this time. 2. Contact the Infection Control Department and Laboratory Medicine. 3. Close the emergency department. 4. Call for more staffing to handle all the patients. Answer: 2 Explanation: 1. Many people must be alerted at this time. 2. Healthcare providers must be alert when there is a change in the trend of symptoms within patients. The infection control nurse should be contacted. Laboratory medicine will run tests on specimens that would otherwise be discarded. The public health department is also contacted with this information. 3. Closing the emergency department would not be necessary. 4. Staffing may need to be adjusted based on the number or acuity of patients, not just a trend in symptoms. Page Ref: 164 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.3 Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 3. Differentiate between the types of terrorism and associated injuries.

27 ..

28) A patient is concerned about a terrorist attack because of living near the airport. Which response should the nurse make? 1. "Have you thought about moving?" 2. "That's silly to be so worried." 3. "What do you have in your home to help you in the event of a terrorist attack?" 4. "I would be concerned, too." Answer: 3 Explanation: 1. Moving because of this fear is not realistic, and the suggestion does little to assist the patient at this time. 2. The nurse should not discount the patient's fears. 3. The general public looks to nurses for information and trusts that what the nurse advises is true and accurate. The nurse should ask the patient what he or she has prepared in the home should there be a terrorist attack. 4. The nurse should not compound the patient's fears. Page Ref: 161 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

28 ..

29) The nursing staff is planning to attend a presentation on disaster prevention. What should the nurse expect the purpose of this education to be? 1. Learn the organization's disaster plan 2. Participate in the plan for handling a disaster 3. Educate on how to recognize possible terrorists 4. Learn how to participate in mitigation Answer: 4 Explanation: 1. The staff should already be familiar with the organization's disaster plan. 2. The focus of the program is prevention, not handling a disaster that has already taken place. 3. Recognition of terrorists is not the focus of the nursing team. 4. Mitigation is the action taken to prevent or reduce the harmful effects of a disaster on human health or property. A key nursing activity related to mitigation is the active participation in learning activities to be able to teach the general public. Page Ref: 170 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

29 ..

30) The community is holding a memorial service to honor members whose lives were lost in a flood one year ago. In which stage of the disaster recovery process is this community? 1. Restoration 2. Recovery 3. Mitigation 4. Evaluation Answer: 2 Explanation: 1. Restoration is a recovery stage in which rebuilding takes place. 2. In the recovery and reconstruction phase, restoration and reconstitution take place. This stage involves rebuilding and returning to some semblance of normalcy. 3. Mitigation activities focus on the prevention or reduction of the harmful effects of a disaster. 4. The evaluation phase involves determining what worked and what did not work and what anticipated and unanticipated issues and challenges emerged. Page Ref: 163 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

30 ..

31) During a disaster preparedness presentation, the nurse learns about the harmful effects of a dirty bomb. Which treatment should the nurse realize will preserve life in the event of this disaster? 1. Support for the patient who will develop radiation sickness 2. Heart-lung transplant 3. Liver transplant 4. Bone marrow transplant Answer: 4 Explanation: 1. While the provision of support is important for patients who have developed radiation sickness, it does not directly preserve life. 2. Transplantation of a heart or lung will not reduce the damage caused by the radiation exposure of a dirty bomb. 3. Transplantation of a liver will not reduce the damage caused by the radiation exposure of a dirty bomb. 4. Radiation sickness results from exposure to a dirty bomb. While this condition can be deadly, it is survivable with bone marrow transplantation. Page Ref: 167 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

31 ..

32) A patient is brought into the emergency department with chemical burns. What should the nurse do to help this patient? 1. Check to see if all clothing has been removed and begin flushing the patient's skin with water. 2. Begin flushing the patient's clothes and skin with warm water. 3. Do not remove any jewelry. 4. Keep the patient's contact lenses in place and flush only with warm water. Answer: 1 Explanation: 1. After the chemical exposure, the patient's clothing should be removed. 2. The chemical should be flushed from the skin with copious amounts of cool running water. 3. Jewelry should be removed. 4. Contact lenses should be removed. Page Ref: 165 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

32 ..

33) The National Weather Service has announced the likelihood of a large snow event in a major metropolitan area. For which type of health problem should the nurses in the emergency department prepare? 1. Stress-related injuries 2. Crushing injuries 3. Myocardial infarctions 4. Burns Answer: 3 Explanation: 1. Stress-related injuries would result from a situation that promotes anxiety. A snow event would not fulfill that criterion. 2. Crushing injuries would result from something falling on individuals. Snow does not meet that criterion. 3. Overexertion and exhaustion are major problems during the snow shoveling following a major snowstorm. The exertion required to shovel heavy snow in the extreme cold can cause myocardial infarction. 4. Burn injuries do not typically accompany snowfall. Page Ref: 167 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

33 ..

34) The emergency response team is setting up an area in which to triage victims of a building blast in a major metropolitan area. Which zone should the nurse identify to set up the location for triage? 1. Hot 2. Warm 3. Cold 4. Clean Answer: 3 Explanation: 1. The hot zone is closest to the site of the disaster. Decontamination takes place in the hot zone. It would not provide the needed safety to perform in-depth triage activities. 2. The warm zone serves as a location for decontamination of victims. Personal protective equipment is needed. It is not a safe location for the in-depth triage. 3. The cold zone is considered the safe zone. It is the area in which a more in-depth triage of victims can be performed. 4. None of the zones is referred to as a clean zone. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

34 ..

35) The nurse is planning the coding for a triage disaster plan. Which colors should the nurse use for this plan? Select all that apply. 1. White 2. Red 3. Yellow 4. Black 5. Green Answer: 2, 3, 4, 5 Explanation: 1. The color white is not used in triage systems. 2. Red is one of the four basic colors used in triage systems. Red is considered critical. 3. Yellow is one of the four basic colors used in triage systems. Yellow indicates a victim who is stable but still needs attention at a hospital. 4. Black is one of the four basic colors used in triage systems. It represents a victim who has died or is unlikely to survive. 5. Green is one of the four basic colors used in triage systems. It indicates minor injuries. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

35 ..

36) A female arrives at the site of a disaster, hysterically crying because of being in the building that collapsed just minutes earlier. What should the nurse do with this patient? 1. Advise to go home and be with family. 2. Triage the patient and transport to the hospital. 3. Have a nurse talk with the patient. 4. Ask psychiatric service personnel to talk with this patient. Answer: 4 Explanation: 1. The patient is very upset and should not be sent away without any intervention. 2. The patient escaped the building before it collapsed and experienced no injuries. Triage services need to be preserved for those who suffered injuries. 3. This patient requires the assistance of psychiatric personnel. 4. Social Services personnel or psychiatric service personnel should be available to assist the worried to cope with the trauma they have just experienced, witnessed, or heard about through the media. Page Ref: 170 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Crisis Intervention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

36 ..

37) An older patient asks what can be done to prepare for a disaster in the community. How should the nurse respond? 1. "There is not really much we can do to be prepared." 2. "Plan to evacuate your home at a moment's notice." 3. "Make sure all your important papers, health information, medication information, and nextof-kin information is in one place." 4. "Make sure you can call your family to come and pick you up if this happens." Answer: 3 Explanation: 1. Planning can significantly reduce adverse outcomes in the event of a disaster. 2. Not all disasters require immediate evacuation from the home. 3. The nurse should suggest this patient be prepared. One step is to have a current list of medications, doses, and times of administration that should be kept in an easily accessible, secure place. The names and phone numbers of significant persons, relatives, those with power of attorney, healthcare providers, and any others to be notified in case of emergency should also be kept in an easily accessible place. 4. Phone communication may not be possible during the initial phases of a disaster. Page Ref: 172 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

37 ..

38) A patient is coded red after a mass casualty accident. What care should the nurse provide to this patient? 1. Send the patient home. 2. Evaluate the patient in the next few hours. 3. Immediately evaluate this patient. 4. Permit the family to be with the patient as death approaches. Answer: 3 Explanation: 1. Green coding means home care would be sufficient. 2. Yellow means that the patient can be evaluated within a few hours. 3. Red means the patient needs life-saving intervention. 4. Black means the patient will most likely die from the injuries. Page Ref: 169 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

38 ..

39) Utilizing the simple triage and rapid transport (START) system, in what order should the nurse prioritize the following patients? Place in order the steps of the process. Choice 1. A 67-year-old male complaining of chest pain. His heart rate is 120 beats/minute, his blood pressure is 100/68 mmHg, and his respiratory rate is 20 breaths/min. Choice 2. A 27-year-old woman presenting with a respiratory rate of 36 breaths/minute and capillary refill of 4 seconds. Choice 3. A 58-year-old woman who is able to walk on her own and states over and over, "I don't know what happened." Choice 4. A 30-year-old male with a collapsed airway and multiple chest trauma. He does not have a palpable carotid pulse and the nurse is unable to assess respiratory movement. Answer: 2, 1, 3, 4 Explanation: Choice 1. Those patients who are in less critical condition but still need to be transported to emergency centers for care are classified as yellow. These patients will require some medical attention but will not die if care is delayed. Their respiratory status is stable and they can follow simple commands. Choice 2. Patients whose respiratory rate is above 30 and capillary refill is greater than 2 seconds should be tagged red and have first priority of care. Choice 3. Patients who have minor injuries and do not warrant transport to an emergency center are categorized as green. They can walk and take care of themselves. Choice 4. Patients who are least likely to survive or are already deceased are color coded as black. This category would include patients who are not breathing and remain apneic even after the airway is manually opened. Page Ref: 169 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

39 ..

40) There is a radiologic dispersion bomb (dirty bomb) explosion in a subway station. In what order should the nurse deliver patient care at the scene of the explosion? Place in order the steps of the process. Choice 1. Begin direct patient care for complaints of fatigue and nausea. Choice 2. Decontaminate clothing of patients. Choice 3. Assess patients for burns and blunt trauma. Choice 4. Evacuate patients from the exposure area. Answer: 3, 4, 2, 1 Explanation: Choice 1. There may be some early complaints of radiation exposure such as nausea or fatigue. The manifestations of serious radiation exposure may not occur for several hours and do not suggest imminent death. Care should begin after the victims have been evacuated from the exposure area. Choice 2. Decontamination should begin as soon as patients are evacuated from the exposure area. Choice 3. The major activities performed for patients who have suffered a dirty bomb blast are triage, evacuation or sheltering, search and rescue, radioactive monitoring, decontamination, and direct patient care. The patient will be assessed for injuries such as burns or blunt trauma. Choice 4. The second step is to evacuate the victims from the exposure area, along with the healthcare providers and first responders. Page Ref: 167 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7.4 Differentiate the common injuries associated with various types of disasters. MNL Learning Outcome: 2. Differentiate between the types of disasters and associated injuries.

40 ..

41) A local hospital has coordinated with the county emergency management team to plan and conduct disaster drills on a monthly basis. In which phase of disaster management planning is this hospital functioning? 1. Preparedness 2. Mitigation 3. Response 4. Evaluation Answer: 1 Explanation: 1. Preparedness refers to proactive planning and preparation while the threat of a disaster is still in the future. Efforts are aimed at developing a disaster response prior to occurrence. 2. The mitigation phase occurs when there is knowledge about an impending disaster that has not yet occurred and includes measures to reduce the harmful effects. Activities during this stage include warning, pre-impact mobilization, and evacuation if appropriate. 3. The response phase involves the immediate response to the effects of the disaster. 4. The final stage of recovery is the evaluation phase, which involves determining what worked and what did not work, and what anticipated and unanticipated issues and challenges emerged. Page Ref: 161 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

41 ..

42) The administrator of a multihospital healthcare system contacts the National Response Framework (NRF) for help with managing care for victims of a flood. What assistance should the administrator expect to receive from this organization? Select all that apply. 1. Standing orders used when caring for victims of a flood 2. Information about local relief agencies available to assist 3. Frequency in which the area has flooded over the last 10 years 4. Amount of time a flood victim can withstand submersion in cold water 5. Names of organizations within the private sector that can help the victims Answer: 2, 5 Explanation: 1. The NRF does not supply specific information about caring for victims of emergencies or disasters. 2. The NRF is a national effort designed to integrate resources of the local, state, and federal governments and includes voluntary relief agencies, the private sector, and international resources if needed to provide assistance to communities following natural or humangenerated disasters. 3. The NRF does not supply statistics about disasters. 4. The NRF does not supply specific information about caring for victims of emergencies or disasters. 5. The NRF a national effort designed to integrate resources of the local, state, and federal governments and includes voluntary relief agencies, the private sector, and international resources if needed to provide assistance to communities following natural or humangenerated disasters. Page Ref: 162 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

42 ..

43) A community hospital has been notified of a plane crash that occurred during a local air show. Which information will the hospital leadership need to prepare for the crash victims? Select all that apply. 1. Number of families who live in the community 2. Number of available beds in the hospital 3. Telephone list of staff to be called in to work immediately 4. Amount of intravenous fluids and emergency medications 5. List of current patients who can be immediately discharged Answer: 2, 3, 4, 5 Explanation: 1. Knowing the number of families who live in the community will not help with planning for the victims of this disaster. 2. Hospitals must be constantly aware of the number of beds available. 3. Hospitals must be constantly aware of staffing. 4. Hospitals must be constantly aware of equipment and medications on hand. 5. Hospitals must be constantly aware of which patients may be discharged. Page Ref: 162 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.2 Outline the five phases of the disaster continuum and discuss the nurse's role in each. MNL Learning Outcome: 1. Demonstrate understanding of emergencies, disasters, and the disaster continuum.

43 ..

44) The nurse notes that a large number of community members with diabetes have experienced insufficient glucose control and cold symptoms since a tornado ripped through the area a few weeks ago. What should the nurse consider as the cause for these symptoms? Select all that apply. 1. Blood stasis in extremities 2. Hindered immune response 3. Change in basal metabolic rate 4. Paralysis of gastrointestinal tract 5. Alteration in nutrient metabolism Answer: 2, 3, 5 Explanation: 1. Blood pooling in extremities leads to thrombus formation. 2. In response to stress, the immune response is suppressed, leading to the onset of infections. 3. In response to stress, the basal metabolic rate changes, which alters protein, carbohydrate, and lipid metabolism. 4. Paralysis of gastrointestinal tract function affects elimination. 5. In response to stress, the basal metabolic rate changes, altering protein, carbohydrate, and lipid metabolism. Page Ref: 171 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

44 ..

45) Survivors of a bioterrorist attack are receiving basic care and support in a local motel until further plans for placement can be made. Several of these victims have been receiving care for autoimmune disorders. What should the nurse consider when providing these victims with food over the next several hours? Select all that apply. 1. Offer fresh salads. 2. Ensure that fruit is fresh. 3. Provide bottled water. 4. Provide cooked or processed meals. 5. Fill pitchers with tap water. Answer: 3, 4 Explanation: 1. Fresh foods should be avoided because of the risk of contamination and subsequent infection. 2. Fresh foods should be avoided because of the risk of contamination and subsequent infection. 3. Bottled water should be ready so the patient can avoid drinking water of questionable purity. 4. Processed or canned foods are safest for this population. 5. Bottled water should be provided so that water of questionable purity can be avoided. Page Ref: 172 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

45 ..

46) A series of thunderstorms ripped through a small town, causing massive power outages. The community nurse is reviewing the list of community members who might be adversely affected by the loss of power. For which residents should the nurse provide immediate care and support? Select all that apply. 1. 16-year-old male with asthma 2. 75-year-old male with sleep apnea 3. 72-year-old male with a pacemaker 4. 45-year-old female with multiple sclerosis 5. 86-year-old female who requires continuous oxygen 2 liters nasal cannula Answer: 2, 5 Explanation: 1. The child with asthma will most likely not need additional support at this time. 2. The patient with sleep apnea might not be able to use the equipment without electricity. The nurse should provide care and support to this patient. 3. The patient with a pacemaker most likely will not need emergency support at this time. 4. The patient with multiple sclerosis most likely will not need emergency support at this time. 5. The patient who requires continuous oxygen will need immediate support because the oxygen concentrator needs electricity to run. Page Ref: 172 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.9. Use clinical judgment and decision-making skills in appropriate, timely nursing care during disaster, mass casualty, and other emergency situations | NLN Competencies: Context and Environment; Practice-KnowHow; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7.5 Describe the interprofessional care and nursing care of patients in a disaster. MNL Learning Outcome: 4. Utilize the nursing process in the care of patients in a disaster.

46 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 8 Genetic Implications of Adult Health Nursing 1) A female patient reports being genetically predisposed to type 2 diabetes. What is the most important information that the nurse should provide? 1. The importance of maintaining a healthy weight and activity level 2. The need to avoid carbohydrate intake 3. The need to begin monitoring daily blood glucose levels 4. The need to address active health problems and not those that have yet to manifest Answer: 1 Explanation: 1. The nurse must be able to identify both community-based and genetic-based resources that are available to assist the patient in strategies to support both health promotion and health maintenance activities. The best way for this patient to avoid illness is to maintain a healthy weight and activity level. 2. While nutrition is a significant factor, it is not necessary to avoid carbohydrates. 3. Daily monitoring of blood glucose levels is not indicated for this patient. 4. It is important to take action to prevent disease and not wait for the disease to manifest. Page Ref: 193-194 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

1 ..

2) A patient tells the nurse that she does not want to pass on a disease that is genetic in origin to any future children. How should the nurse respond to this patient? 1. "A complete genetic study could help guide you in your decision making." 2. "I suppose, then, that you are not going to have any children." 3. "Adoption is always a possibility." 4. "Are you sure that the disease is genetic in origin?" Answer: 1 Explanation: 1. Findings from genetic research can be used by patients and family members to improve their own health and prevent illness. According to the ANA/ISONG, all registered nurses must have an understanding of genetics to identify, support, and care for patients who have or who may transmit genetic conditions. 2. It is premature to suggest refraining from having children until the genetic study is completed. 3. It is premature to suggest adoption until the genetic study is completed. 4. Questioning whether a specific disease is genetic in origin may be helpful, but may not allay the patient's concerns about other diseases. Page Ref: 180 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

2 ..

3) A patient expresses concern about transmitting genetic illnesses to any future children. What can the nurse do to help the patient determine which diseases might be transmitted? 1. Complete a pedigree. 2. Conduct a health promotion assessment. 3. Schedule a complete genetic analysis. 4. Refer to a geneticist for diagnosis. Answer: 1 Explanation: 1. A pedigree is a pictorial representation or diagram of the medical history of a family that typically includes three generations. Multiple symbols are utilized to present this picture, and the finished pedigree presents a family's medical data and biologic relationship information at a glance. Since a pedigree provides the nurse, genetic counselor, or geneticist with a clear, visual representation of relationships of affected individuals to the immediate and extended family, it needs to be completed before scheduling a complete genetic analysis or being referred to a geneticist for diagnosis. 2. Conducting a health promotion assessment will not provide information regarding the patient's risk for passing on genetic illnesses to future children. 3. Scheduling a complete genetic analysis is not the first action to address a patient's concern about transmitting genetic illnesses to children. 4. Referring the patient to a geneticist is not the first action to take to address a patient's concern about transmitting genetic illnesses to children. Page Ref: 190 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

3 ..

4) At the completion of a genetic assessment, the nurse learns that a patient has three family members diagnosed with rectal cancer before the age of 40 years. What should the nurse discuss with the patient? 1. Importance of having screening for colorectal cancer at an earlier age 2. Importance of ingesting a diet high in protein and carbohydrates 3. Ways to maximize time spent in exercise 4. Reasons why having children would not be recommended for this patient Answer: 1 Explanation: 1. The information from the genetic assessment identified three family members diagnosed with rectal cancer before the age of 40 years. The nurse should discuss with the patient the importance of having screening for colorectal cancer at an earlier age. 2. Ingesting a diet high in protein and carbohydrates is not going to reduce the patient's risk for developing the disease. 3. Maximizing exercise is not going to reduce the patient's risk for developing the disease. 4. Counseling the patient on abstaining from having children is not going to improve the patient's risk for the disease. Page Ref: 193 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

4 ..

5) While assessing a patient, the nurse notes an irregularity that has been observed in other patients, but on an inconsistent basis. What did the nurse most likely discover in this patient? 1. A polymorphism 2. A mutation 3. A single-gene inheritance pattern 4. An X-linked inheritance pattern Answer: 1 Explanation: 1. A polymorphism is a change in DNA sequence that has been identified in more than 1% of the population and is more commonly observed than a mutation. Polymorphisms differ from mutations in that they are observed more frequently in the general population than mutations. 2. A mutation is a change in a single gene. 3. A single-gene inheritance pattern will follow a pattern of being present in every member of a generation or will skip a generation, depending if the alteration is dominant or recessive. 4. In the X-linked inheritance pattern, the mutant gene is located on the X chromosome. Males have only one X chromosome with no counterpart for its genes, therefore the alteration will appear in all males. Because the female as two X chromosomes, the alteration may or may not occur. Page Ref: 184 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

5 ..

6) A pregnant patient is informed that the fetus most likely has Down syndrome. With which genetic finding is this diagnosis most consistent? 1. Trisomy 2. Monosomy 3. Translocation 4. Deletions Answer: 1 Explanation: 1. Trisomy refers to the presence of a third or extra chromosome instead of the normal pair of a particular chromosome. The most common type of trisomy in infants is trisomy 21 or Down syndrome. 2. Monosomy refers to the presence of only one chromosome instead of the normal pair of chromosomes. 3. Translocation (chromosomal reshuffling) occurs when a segment of a chromosome transfers or moves and attaches itself to another chromosome. 4. Structural rearrangements of chromosomes may result from deletions or loss of a chromosome segment or piece. Page Ref: 182 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

6 ..

7) A patient reports that many family members have a type of anemia that is genetic. What should the nurse realize will occur in this patient? 1. The patient will develop the disease only if there is a mutation in the gene. 2. The patient will develop the same type of anemia. 3. The patient will die from the anemia. 4. The patient will develop the disease only if the gene translocates. Answer: 1 Explanation: 1. All humans have essentially the same 20,000 to 30,000 genes; it is the mutation or polymorphism in the gene that predisposes some individuals for disease, not translocation nor the gene itself. 2. The patient may or may not develop anemia. 3. The patient may or may not die from anemia. 4. Translocation does not predispose some individuals for disease. Page Ref: 182 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

7 ..

8) At the completion of genetic testing it has been determined that a patient's baby will have Down syndrome. What should the nurse say to the patient after learning this information? 1. "I realize that this news is difficult for you. Is there anything that I can do to help you at this time?" 2. "It's not too late to consider ending the pregnancy." 3. "You are young enough to be able to handle the baby's challenges." 4. "It does not matter if the baby has problems; all life is precious." Answer: 1 Explanation: 1. Nurses should encourage open discussions and the expression of fears and concerns. When supporting a pregnant patient who learns that the baby has Down syndrome, the best response for the nurse to make would be to acknowledge that the news is difficult and offer to help the patient. 2. The nurse should not suggest that the patient terminate the pregnancy. 3. The nurse should not tell the patient that the baby will have challenges that will need to be met by a young person. 4. Stating that all life is precious is judgmental and should not be stated by the nurse. Page Ref: 193 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Caring Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

8 ..

9) The nurse is developing a teaching plan for parents who need genetic counseling. Which statement by a parent indicates the need for further education? 1. "All the chromosomes are the same size in males and females alike." 2. "Half of the sets of chromosomes come from the mother and the other half comes from the father." 3. "The 23rd pair of chromosomes will determine if our child will be male or female." 4. "One Y chromosome and one X sex chromosome will produce a male child." Answer: 1 Explanation: 1. A basic understanding of the cell, DNA, cell division, and chromosomes is important for young families receiving genetic counseling. The cell nucleus contains about 6 feet of DNA that are tightly wound and packaged into 23 pairs of chromosomes, making a complete set of 46 chromosomes. There are two copies of each chromosome. One copy, or half of the complete set of these 46 chromosomes, is inherited from the mother, and the other copy is inherited from the father. Chromosomes are numbered according to size, with chromosome 1 being the largest and chromosome 22 being the smallest. 2. One copy, or half of the complete set of these 46 chromosomes, is inherited from the mother, and the other copy is inherited from the father. The first 22 pairs of chromosomes are alike in males and females. 3. The 23rd pair, the sex chromosomes, determines an individual's gender. 4. A female has two copies of the X chromosomes and a male has one X chromosome and a Y chromosome. These X and Y chromosomes are known as sex chromosomes. Page Ref: 181 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

9 ..

10) After genetic testing, a patient learns of having a predisposition for developing cardiovascular disease at a young age. What should the nurse instruct the patient regarding this information? 1. "This information can help guide you to make lifestyle changes to reduce the chance of developing cardiovascular disease." 2. "At least you know now that you will need cardiac bypass surgery." 3. "Since you will most likely develop the disease early in life, enjoy your life as much as possible now." 4. "I would not place too much emphasis on these test results because most of the time they are inconclusive." Answer: 1 Explanation: 1. One benefit of genetic testing is that it allows for preventive measures and lifestyle adaptations. The nurse should instruct the patient on how this information can serve as a guide to make lifestyle changes to reduce the risk of developing cardiovascular disease. 2. The nurse has no way of knowing whether the patient is going to need cardiac bypass surgery or not. 3. The nurse should not encourage the patient to enjoy life as much as possible now since this might lead to high-risk behaviors. 4. The nurse should not minimize the importance of the genetic testing results. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

10 ..

11) A patient planning to be married has a strong family history of Huntington chorea but does not plan to inform the future spouse. How should the nurse respond to this patient? 1. "Is there any reason why you do not want your fiancé to know about the genetic illness?" 2. "It is probably best that the disease is not discussed." 3. "Are you afraid that your future marriage will be jeopardized?" 4. "There are worse disease processes than Huntington chorea." Answer: 1 Explanation: 1. The nurse needs to support the patient in ethical and social issues. The best response from the nurse would be to ask the patient if there is any reason why the future spouse should not be informed about the genetic illness. 2. Agreeing that the future spouse should not be made aware would be an inappropriate response for the nurse to make. 3. Suggesting that the future spouse would not want to marry the patient if aware of the genetic disease is also an inappropriate response for the nurse to make. 4. The nurse should not make a judgment statement by saying that there are worse disease processes than Huntington chorea. Page Ref: 190 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VII.11. Access interprofessional and intraprofessional resources to resolve ethical and other practice dilemmas | NLN Competencies: Patient-Centered Care; Ethical Comportment; Respect the patient's dignity, uniqueness, integrity, and self-determination, and his or her own power and self-healing processes | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

11 ..

12) A patient planning to have genetic testing prior to having children is fearful that too many people will learn about the test. How should the nurse respond to this patient? 1. "The results of the tests are confidential and no one can have the results without your permission." 2. "Most insurance companies will want the results before paying for the tests." 3. "The results will be available to anyone who reviews your medical record." 4. "The healthcare provider will most likely use the results when planning care and treatment for other patients with the same genetic disorder." Answer: 1 Explanation: 1. The nurse should explain that the results of genetic testing are confidential and that written permission to have access to the results will be needed by the patient. 2. Insurance companies will not need the results of the tests before paying for the tests. 3. The results will be confidential and not accessible by anyone who reviews the patient's medical record. 4. The patient's physician cannot use the test results when planning care and treatment for other patients with the same genetic disorder. Page Ref: 189 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.7. Explore ethical and legal implications of patientcentered care | AACN Essentials Competencies: VII.11. Access interprofessional and intraprofessional resources to resolve ethical and other practice dilemmas | NLN Competencies: Context and Environment; Knowledge; ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

12 ..

13) After learning of a genetic disease, a patient is upset because no other siblings have the disease and it is proof that the patient was unwanted by the parents. What should the nurse counsel this patient? 1. Suggest the patient talk with a counselor to discuss the results of the test and future options. 2. Ask the patient if thoughts and fears were discussed with the parents. 3. Encourage the patient to talk with the siblings about the illness and ask them for help now before the disease manifests. 4. Remind the patient that genetic testing is inconclusive, and there is a great chance that the results are wrong. Answer: 1 Explanation: 1. Individuals learning of genetic testing results can have feelings of anger, guilt, confusion, and depression. The nurse should suggest that the patient talk with a counselor to discuss the test results and future options to help the patient work through his feelings. 2. The nurse should not suggest that the patient confront the parents. 3. The nurse should also not suggest that the patient discuss the test results with siblings in order to elicit their help and support before the disease manifests. 4. Genetic testing is conclusive. This would be an inappropriate suggestion to make to the patient. Page Ref: 190 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication | AACN Essentials Competencies: VII.11. Access interprofessional and intraprofessional resources to resolve ethical and other practice dilemmas | NLN Competencies: Context and Environment; Knowledge; ethical decision-making models | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

13 ..

14) A patient believes that a newborn has a genetic disorder because someone gave the baby the "evil eye." What should this information suggest to the nurse? 1. The patient's culture supports the notion that a stranger looking at the baby caused the disorder. 2. The patient needs psychiatric counseling. 3. The patient is not going to be a good mother since strangers are permitted around the baby. 4. Healthcare dollars should not be spent trying to change this patient's opinion of why the baby has a genetic disorder. Answer: 1 Explanation: 1. The nurse needs to be aware of the patient's cultural and religious beliefs. The patient stating that the newborn has a genetic disorder because a stranger gave the baby the "evil eye" is evidence that the patient believes this is the cause of the disorder. 2. This information does not suggest that the patient needs psychiatric counseling or that the patient is not going to be a good mother. 3. This information does not suggest that the patient is not going to be a good mother. 4. Deciding whether healthcare dollars should be spent trying to change the patient's opinion of why the baby has a genetic disorder is beyond the scope of the nurse. Page Ref: 193 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.2. Describe how diverse cultural, ethnic and social backgrounds function as sources of patient, family, and community values | AACN Essentials Competencies: VII.3. Assess health/illness beliefs, values, attitudes, and practices of individuals, families, groups, communities and populations | NLN Competencies: Context and Environment; Ethical Comportment; Show respect for others' values; appreciate diversity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

14 ..

15) A patient has a strong family history of nonpolyposis colorectal cancer. What is the best advice the nurse can give to the patient? 1. Have predispositional genetic testing done to detect the presence of the genetic disorder even though the patient may never develop cancer. 2. Teach the patient the symptoms of colon cancer and suggest a high-fiber diet to prevent cancer. 3. Have regular colonoscopies; if one is abnormal, then predispositional genetic testing is indicated. 4. Have predispositional genetic testing done to detect the presence of colorectal cancer so that treatment can be initiated as early as possible. Answer: 1 Explanation: 1. The patient should be advised to have a predispositional test to detect the presence of the genetic mutation that causes nonpolyposis colorectal cancer. 2. Teaching the patient the symptoms of colon cancer and suggesting a high-fiber diet to prevent cancer are important pieces of advice, but not the best advice for this patient at this time. 3. In this case, genetic testing is indicated. 4. Therapy would be started only if the cancer were present. Page Ref: 189 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

15 ..

16) Through genetic testing, a patient learns of having an apolipoprotein E2 gene. What should this information suggest to the nurse? 1. The patient is at reduced risk for developing Alzheimer disease. 2. The patient is at increased risk for developing Alzheimer disease. 3. The patient is at risk for contracting malaria. 4. The patient is at risk for developing colorectal cancer. Answer: 1 Explanation: 1. The apolipoprotein E gene provides instructions to make a protein that combines with fats in the body to form molecules called lipoproteins that are responsible for packaging cholesterol and other fats and carrying them through the bloodstream. Research has shown that a person who inherits at least one E4 allele will have a greater chance of developing Alzheimer disease. Inheriting the E2 allele seems to indicate that a person is less likely to develop Alzheimer disease. 2. Inheriting the E2 allele does not indicate that a person is more likely to develop Alzheimer disease. 3. The apolipoprotein E gene is not a predictor for contracting malaria. 4. The apolipoprotein E gene is not a predictor for developing colorectal cancer. Page Ref: 184 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

16 ..

17) From genetic testing, a patient learns that a specific medication can help a developing disease process. What does the nurse understand that genetic testing provided for the patient? 1. Biological marker 2. Phenotype 3. Genotype 4. Translocation Answer: 1 Explanation: 1. Biological markers are easily tracked, stable segments of DNA. Information gained from biological markers will provide information on how subtle differences in humans impact the response to drugs and the environment, making medical treatment and pharmacologic management more individualized. 2. The observable, outward expression of an individual's entire physical, biochemical, and physiologic makeup, as determined by their genotype and environmental factors, is referred to as phenotype. 3. The specific sequence of nucleotides is referred to as the individual's genotype. 4. Translocation occurs when a segment of a chromosome transfers or moves and attaches itself to another chromosome. Page Ref: 184 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

17 ..

18) A patient is having difficulty achieving adequate anticoagulation with prescribed doses of warfarin. What should the nurse suspect may be indicated for this patient? 1. Genetic testing to determine if the patient metabolizes warfarin slower 2. Use of a different anticoagulant 3. Review of the patient's diet 4. Analysis of the patient's lifestyle Answer: 1 Explanation: 1. One use of genetic testing involves predicting or studying the patient's response to particular medications. Pharmacogenetic testing has shown that 20% of Caucasians metabolize Warfarin more slowly and take longer to achieve therapeutic dosing. Genetic testing could help determine why the patient has not achieved successful anticoagulation. 2. There might not be another anticoagulant available for the patient. 3. Reviewing the patient's diet might provide some information regarding dietary reasons for the unsuccessful anticoagulation of the patient. 4. An analysis of the patient's lifestyle will not help determine why the patient has not achieved successful anticoagulation. Page Ref: 189 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

18 ..

19) A patient's mother has type 2 diabetes and heart problems. What should this information indicate to the nurse? 1. Patient will probably not change health habits 2. Can help predict the patient's future health problems 3. Helps predict the future health of the patient's children 4. Patient keeps in touch with parents Answer: 2 Explanation: 1. There is no evidence that the patient would not change any health habits. 2. Even though most individuals do not know their genetic makeup, the nurse can help plan strategies to promote and maintain health for the patient. Family history has long been a part of nursing assessment, but the relative importance of obtaining a family history has recently increased as our knowledge of the interaction of genes and the environment has expanded. In fact, it is an inexpensive first genetic screen, often underused by healthcare professionals. 3. Although the family health history is significant, it will not provide a direct prediction for the patient's children. 4. Information to determine the relationship between the patient and family is not given. Page Ref: 190 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

19 ..

20) A healthcare provider has prescribed a chromosomal analysis for a newborn baby. Which test does the nurse realize will most likely be performed with this baby? 1. Karyotype 2. Newborn screen 3. Carrier testing 4. Preimplantation genetic diagnosis Answer: 1 Explanation: 1. The karyotype provides an analysis of the number and structure of the chromosomes. 2. Newborn screening is performed shortly after birth. It seeks to identify inborn errors of metabolism. 3. Carrier testing is completed on asymptomatic individuals who may be carriers of one copy of a gene alteration that can be transmitted to future children in an autosomal recessive or Xlinked pattern of inheritance. 4. Preimplantation genetic testing involves the detection of disease-causing gene alterations in human embryos just after in vitro fertilization and before implantation in the uterus. Page Ref: 182 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

20 ..

21) A 42-year-old pregnant patient asks if the baby will be born with Down syndrome because of a chromosomal abnormality. To which chromosomal abnormality should the nurse understand the patient is referring? 1. 23 pairs of chromosomes 2. 26 pairs of chromosomes 3. One member of a chromosome pair missing 4. One extra member of a chromosome pair Answer: 4 Explanation: 1. The abnormality being described is not 23 pairs of chromosomes. 2. The abnormality being described is not 26 pairs of chromosomes. 3. The abnormality being described is not one that has a missing member of a chromosome pair. 4. A zygote that is trisomic, or one that has three chromosomes instead of the usual 2, can produce the condition called trisomy 21 or Down syndrome. The specific chromosome involved with this disorder is number 21. That is the abnormality being described. Page Ref: 182 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

21 ..

22) A patient whose spouse has chronic myelogenous leukemia is concerned that future children will inherit that genetic disorder. How should the nurse respond to this patient? 1. "The genetic makeup that created the chronic myelogenous leukemia in your spouse is not inheritable." 2. "I would be concerned, too." 3. "Maybe you should re-think having children." 4. "It could cause the same disorder, but it's a decision that you will have to make." Answer: 1 Explanation: 1. The chromosome translocation that is responsible for chronic myelogenous leukemia is not inheritable. 2. It is not appropriate to agree with the patient at this time. This may increase her level of concern needlessly. 3. Offering advice that is not in the best interest of the patient and family is not considered therapeutic communication. 4. Offering advice that is not in the best interest of the patient and family is not considered therapeutic communication. Page Ref: 183 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

22 ..

23) A male patient has a history of a genetic disorder and is concerned that this same disorder will be passed to future children. What information should the nurse provide to this patient? 1. All genetic disorders are passed to future children. 2. If the genetic disorder is a disorder of metabolism, it will most likely not be passed to any children. 3. The best possible plan for this problem is to avoid children. 4. The children will inherit the disorder only if the disorder is on chromosomes 13, 18, and 21. Answer: 2 Explanation: 1. Mitochondrial genes and any diseases due to DNA alterations on those genes are transmitted through the mother in a matrilineal pattern. An affected female will pass the metabolism DNA mutation to all children. An affected male will not pass the metabolism DNA mutation to any of his children. 2. Mitochondrial genes and any diseases due to DNA alterations on those genes are transmitted through the mother in a matrilineal pattern. An affected female will pass the metabolism DNA mutation to all children. An affected male will not pass the metabolism DNA mutation to any of his children. 3. It is inappropriate for the nurse to recommend that the patient not have children. This recommendation steps beyond the scope of practice. 4. Inherited disorders exist beyond those involving chromosomes 13, 18, and 21. Page Ref: 183 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

23 ..

24) A baby is born with a genetic disorder that did not affect either of the parents. What should the nurse realize about this baby's disorder? 1. The mother is the carrier of the disorder. 2. The father is the carrier of the disorder. 3. The father is not the biological father of the baby. 4. Both parents are carriers of the disorder. Answer: 4 Explanation: 1. If only one parent were affected, the child would not be born with the disorder but simply would be a carrier as well. 2. If only one parent were affected, the child would not be born with the disorder but simply would be a carrier as well. 3. There is no evidence that the father is not the biological father. 4. A child born with a recessive condition has inherited one altered gene from the mother and one from the father. In most cases, neither of the parents is affected and therefore, each of the parents must have a single gene alteration on one chromosome of a pair and the normal, wildtype, or unaltered, form of the gene on the other chromosome. These parents would be known as carriers of the condition and they do not usually exhibit any signs and symptoms of the condition. Page Ref: 184 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

24 ..

25) A baby is born with a genetic disorder, and neither parent has a history of this disorder. What should the nurse use to explain the baby's genetic disorder? 1. De novo 2. Penetrance 3. An X-linked dominant condition 4. Multifactorial conditions Answer: 1 Explanation: 1. When there is no previous history of a condition, including even subtle signs and symptoms of the disease, in any immediate or distant family member, the disease may be caused by a spontaneous new mutation. This is called de novo. 2. Penetrance is the probability that a gene will be expressed phenotypically. 3. X-linked conditions are recessive in nature. 4. Multifactorial conditions occur as a result of genetic variations and lifestyle and environmental influences that work together. Page Ref: 187 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

25 ..

26) Upon the completion of genetic testing, a patient is happy to learn of a negative test result. What should the nurse explain to the patient? 1. The patient will never experience a genetically caused disease. 2. Any children will be free from genetic diseases. 3. Children might develop disease from genetic misplacement of chromosomes. 4. There is no guarantee that the patient will not develop the disease. Answer: 4 Explanation: 1. A negative test result cannot guarantee that the disease or condition might not develop in the future. 2. The patient's children may experience random chromosomal abnormalities that are seen in the rest of the population. 3. This is not necessarily true. 4. A negative test result cannot guarantee that the disease or condition might not develop in the future. The patient's children may experience random chromosomal abnormalities that are seen in the rest of the population. Page Ref: 189 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

26 ..

27) A patient and future spouse are upset because genetic testing completed through a laboratory found on the Internet determined they are at risk for having children with congenital abnormalities. Which is an appropriate nursing response? 1. "A screening test should be confirmed with a diagnostic test." 2. "The decision about whether or not to have children has been made for you." 3. "Are you concerned that your future spouse won't want to get married now?" 4. "I wouldn't worry about those results." Answer: 1 Explanation: 1. A positive screening genetic test result indicates an increased risk or probability but must always be confirmed by diagnostic testing. 2. The nurse is offering advice. 3. This statement may be offensive to the patient. 4. The nurse should not tell the patient and future spouse that the testing is not valuable. Page Ref: 188 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

27 ..

28) A patient reports that an adolescent child with a congenital abnormality is demonstrating increasing anger and animosity toward the parents. In which way is the adolescent behaving? 1. As a normal teenager 2. Confused and unaware of how to express it 3. Fostering resentment toward his parents 4. Demonstrating disease from the congenital abnormality Answer: 3 Explanation: 1. Normal adolescents do not have to manage the implications associated with the occurrence of a congenital abnormality. 2. The patient is not exhibiting behavior consistent with confusion. 3. The individual who has inherited an altered disease-producing gene may foster deep resentment toward the parent who carries the altered gene. 4. There is no evidence that these behaviors are related to disease process. There is no information provided to support this assumption. Page Ref: 190 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

28 ..

29) At the conclusion of a genetic counseling session, a family member believes information is being withheld. In which way is this individual behaving? 1. Feeling guilty because of the outcome of the testing 2. Demonstrating signs of a congenital abnormality 3. Angry with the findings from the testing 4. Confused by the nondirective approach taken by the genetic healthcare providers Answer: 4 Explanation: 1. Feelings of guilt are not manifested in the demeanor demonstrated by the patient. 2. There is no information provided concerning the genetic disorder being evaluated. There is an inadequate amount of data presented to link the behaviors with the disorder. 3. Feelings of anger are not manifested in the demeanor demonstrated by the patient. 4. Many patients are accustomed to practitioners and nurses who provide decision-making direction and guidance, so patients may be uncomfortable when the nurse takes the opposite approach. They may believe that the nurse or healthcare provider is withholding very bad news. The nurse should discuss the positives and negatives of each decision and present as many options as possible through the use of therapeutic listening and communication skills. Page Ref: 193 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.9. Discuss principles of effective communication | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

29 ..

30) A baby with Down syndrome has been born to a patient who refuses to allow any family members to visit the newborn. What should the nurse realize this patient is demonstrating? 1. Postpartum depression 2. Denial 3. Anxiety and guilt 4. Poor bonding Answer: 3 Explanation: 1. Postpartum depression is not an immediate response. 2. There is no evidence that the patient is in denial. 3. Nurses must also provide care to help alleviate any patient anxiety or guilt. Anxiety of the unknown is common when awaiting diagnosis or test results, but individuals also experience anxiety from not understanding the future implications of a confirmed genetic disease. Guilt and shame are very common as a patient deals with the loss of the expectation and dream of a healthy child. Guilt may be associated with knowledge of the existence of a genetic condition being in a family. The nurse must support patients as they contemplate telling extended family members, friends, and neighbors about a confirmed diagnosis. Patients often do not want to tell extended family members until they are ready. The nurse should encourage open discussion and expressing fears and concerns. 4. There is no evidence to suggest that the patient is not bonding well with the infant. Page Ref: 191 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

30 ..

31) A patient is upset to hear that the results of genetic testing revealed wild-type genes. In which way should the nurse explain this type of gene? 1. Normal 2. Abnormal with limitations 3. Defective 4. Unexpected Answer: 1 Explanation: 1. A normal or unaltered form of a gene is known as wild-type. 2. Wild-type genes are normal, not abnormal with limitations. 3. Wild-type genes are normal, not defective. 4. Wild-type genes are normal, not unexpected. Page Ref: 184 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

31 ..

32) A patient who is pregnant reports a family history of cystic fibrosis and asks about the risks for transmission to the baby. What concept should the nurse include in the discussion? 1. There is less risk for transmission to male children. 2. The condition does not skip generations. 3. Male and female children are equally affected. 4. Both parents must be affected with this disorder for transmission to occur. Answer: 3 Explanation: 1. Autosomal recessive disorders such as cystic fibrosis are transmitted equally between male and female children. 2. The disorder may appear to skip a generation. 3. Autosomal recessive disorders such as cystic fibrosis are transmitted equally between male and female children. 4. The parents may be carriers of this disorder but not affected. Page Ref: 185 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

32 ..

33) A newborn has just been diagnosed with a negative result from genetic testing. What should the nurse realize this finding means? 1. No further follow-up is needed. 2. There is no clinical explanation for the symptoms that are seen. 3. The baby is likely a carrier of a genetic abnormality. 4. The baby will develop symptoms of a genetic abnormality later in life. Answer: 1 Explanation: 1. If the genetic test was for newborn screening and the result is negative, the newborn will not need diagnostic testing. No follow-up is needed. 2. There is no evidence of a manifestation. Newborn screening is often routine. 3. The test results indicate the baby does not have a genetic disorder. 4. There is no way to predict the baby's future health status. Page Ref: 189 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

33 ..

34) A patient scheduled for a genetic evaluation has questions regarding the visit. Rank the steps in the order that they should most likely occur. Place in order the steps of the process. Choice 1. The geneticist examines the patient. Choice 2. The patient is scheduled for diagnostic tests. Choice 3. The patient constructs a third-generation pedigree. Choice 4. The geneticist discusses the findings with the patient and makes recommendations. Choice 5. The genetic clinical nurse interviews the patient. Answer: 3, 5, 1, 2, 4 Explanation: Choice 1. The third step is for the geneticist to examine the patient. Choice 2. The fourth step is for the patient to be scheduled for diagnostic tests. Choice 3. The first step is for the nurse and patient to construct a third-generation pedigree. Choice 4. The fifth step is when the geneticist discusses the findings with the patient and makes specific recommendations. Choice 5. The second step is for the genetic clinical nurse to interview the patient. Page Ref: 192 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

34 ..

35) The parents of a newborn diagnosed with cri du chat syndrome request information about this disorder. What statement by the nurse is appropriate? Select all that apply. 1. "Your baby's chromosomal makeup is unbalanced." 2. "These types of genetic problems are often the result of the patient missing some genes or having too much genetic material." 3. "This syndrome is genetically related to trisomy 21." 4. "Your baby's syndrome is the result of a large deletion on the short arm of chromosome 5." 5. "Your baby has the low-set ears and mewing cry that is associated with this syndrome." Answer: 1, 2, 4, 5 Explanation: 1. A chromosomal alteration that includes a missing or additional whole chromosome or segment of a chromosome is an unbalanced rearrangement. 2. An unbalanced rearrangement can result in missing genes, confusing directions from the genes, or too much gene product. 3. Translocation between chromosomes 9 and 22 is responsible for trisomy 21. 4. Cri du chat syndrome results from a large deletion on the short arm of chromosome 5. 5. Patients with cri du chat have mental retardation, crying that sounds like a cat mewing, and low-set ears. Page Ref: 182 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

35 ..

36) The nurse working in a geneticist's office is reviewing information about human cells with a patient. Which patient statement indicates that an adequate amount of learning has occurred? Select all that apply. 1. "Every human cell has 23 pairs of chromosomes and a total of 46 chromosomes." 2. "Chromosome 1 will be the smallest while chromosome 46 will be the largest." 3. "Each human cell contains mitochondria." 4. "The 22nd pair of chromosomes determines the person's gender." 5. "Every human cell functions in the same way regardless of its location." Answer: 1, 3 Explanation: 1. Every human cell has 23 pairs of chromosomes. There are 46 chromosomes in each cell. 2. Chromosomes are numbered according to size, largest to smallest. Chromosome 1 is largest and chromosome 46 is smallest. 3. Each human cell contains organelles such as mitochondria. 4. The 23rd pair of chromosomes determines the person's gender. 5. Human cells function very differently based on their location. Page Ref: 181 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

36 ..

37) The nurse is reviewing the process of cell division with a patient receiving care in a fertility clinic. Which statement should the nurse make to explain mitotic cell division? Select all that apply. 1. "Sperm cells use mitosis to divide." 2. "It is the process to heal a wound." 3. "It is the process to recover from bronchitis." 4. "Fetal tissue grows this way." 5. "Healing from a stomach ulcer occurs this way." Answer: 2, 3, 4, 5 Explanation: 1. Sperm cells use meiosis to divide. 2. Mitosis is the process of making new cells in bodily tissue. Cell division through mitosis heals wounds on skin surfaces. 3. The lining of the respiratory tract is replaced through mitosis. 4. A fetus grows through mitotic cell division. 5. The lining of the gastrointestinal tract is replaced by mitosis. Page Ref: 181 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

37 ..

38) A patient with blue eyes asks the nurse to explain eye color because one parent had blue eyes and the other parent had brown eyes. What should the nurse include in this explanation? Select all that apply. 1. "You have two identical alleles that are responsible for your eye color." 2. "The alleles that are responsible for your eye color are heterozygous." 3. "Your eye color is the result of an expressed gene." 4. "Alleles are forms of a gene." 5. "Your eye color is just one part of your phenotype." Answer: 2, 3, 4, 5 Explanation: 1. Because the patient's parents have different eye color, the patient has two different forms of the gene responsible for his eye color. The patient's alleles are heterozygous. 2. The patient's alleles are heterozygous. 3. The patient's blue eyes are the result of an expressed gene. An expressed gene impacts the patient's outward experience. 4. Alleles are versions or forms of a gene. The patient's eye color is part of his phenotype. 5. The phenotype is the patient's entire physical, biochemical, and physiologic makeup and is influenced by genetic and environmental factors. Page Ref: 183 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

38 ..

39) The parents learn that their newborn has the CFTR gene located on chromosome 7. During counseling, what should the parents be instructed about the way that this genetic alteration may be expressed as the child grows? Select all that apply. 1. The child develops normally without any clinical manifestations associated with cystic fibrosis. 2. The patient is placed on a lung transplant list. 3. The patient receives bilateral mastectomies. 4. The patient is counseled about the increased risk of developing Alzheimer disease. 5. The child exhibits some mild signs and symptoms associated with cystic fibrosis. Answer: 1, 2, 5 Explanation: 1. The CFTR gene is a very large gene that is located on chromosome 7. Many different mutations of the CFTR gene have been reported to be associated with the disease. The area of the CFTR gene that controls mucous production can have more than 300 different gene alterations, resulting in a variety of symptoms that range from no clinical manifestations at all to severe problems. 2. The area of the CFTR gene that controls mucous production can have more than 300 different gene alterations, resulting in a variety of symptoms that range from no clinical manifestations at all to severe problems. The patient with severe cystic fibrosis may be placed on a lung transplant list. 3. The CFTR gene does not necessarily increase the patient's risk for developing breast cancer. 4. The CFTR gene does not necessarily increase the patient's risk for developing Alzheimer disease. 5. The area of the CFTR gene that controls mucous production can have more than 300 different gene alterations resulting in a variety of symptoms that range from no clinical manifestations at all to severe problems. The child may experience a mild form of cystic fibrosis. Page Ref: 183 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

39 ..

40) A young adult patient is suspected of having a mitochondrial mutation. Which patient statement is consistent with this information? Select all that apply. 1. "My dad was unable to hear normally after the age of 15." 2. "My mom and my sister are really little when compared to the rest of my family." 3. "My mom and my grandmother have trouble with seizures." 4. "My dad and my uncle both had heart attacks when they were in their 40s." 5. "I have some trouble walking and my muscles seem to be getting weaker." Answer: 2, 3, 5 Explanation: 1. The patient's father developed deafness at an early age, and while this may be the result of a mitochondrial genetic alteration, it is not necessarily as concerning to learn about because the father will be unable to pass this mitochondrial mutation to his child. 2. Mitochondrial genes and any diseases due to DNA alterations on those genes are transmitted through the mother in a matrilineal pattern. An affected female will pass the mtDNA mutation to all of her children. However, an affected male will not pass the mtDNA mutation to any of his children. The patient's mother and sister have small statures, and this may be related to a mitochondrial mutation. 3. The patient's mother and grandmother have a history of seizures, and this can indicate that they are experiencing clinical manifestations associated with mitochondrial mutations. 4. The patient's father and uncle experienced myocardial infarctions at abnormally early ages, and while this may be the result of a mitochondrial mutation, it is not as concerning because the father will be unable to pass this mitochondrial mutation to his child. 5. Manifestations of conditions due to mitochondrial gene alterations primarily involve highenergy tissues and organs such as skeletal muscles. Page Ref: 183 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.1 Outline the basics of genetics including cell division, chromosomal alterations, and the role of genes. MNL Learning Outcome: 1. Demonstrate understanding of the basics of genetics.

40 ..

41) A fetus is found to have an autosomal recessive condition. After genetic testing is completed, both of the fetus' parents are found to have this same autosomal recessive genetic alteration. Which statement made by a parent indicates that further education is required? Select all that apply. 1. "This condition is related to a genetic alteration of the X chromosome." 2. "This condition is a Mendelian condition." 3. "So, we are carriers of this condition because we don't have any signs of symptoms of this condition." 4. "Our baby would have a better chance of living if we would have both been positive for an autosomal dominant condition." 5. "The problem is the result of an alteration of just one single gene." Answer: 1, 4 Explanation: 1. Genetic alterations of the X chromosome are referred to as X-linked recessive or X-linked dominant conditions. 2. This is a Mendelian condition because it follows Mendel's laws of inheritance. 3. The parents denied having any clinical manifestations associated with the condition, so they are most likely carriers of the condition. 4. It is not necessarily true that the infant will die due to an autosomal recessive condition. The baby that is affected by a homozygous autosomal dominant condition is much more likely to die from problems associated with that type of condition. 5. These types of conditions are monogenic because they affect one single gene. Page Ref: 184 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

41 ..

42) A married couple with two children who have the same autosomal dominant health problem is pregnant with a third child. Which statement by the patient may be expected? Select all that apply. 1. "I feel so guilty." 2. "I feel like my daughter is angry with me because I am the one who has this bad gene in my body." 3. "I am depressed and angry with myself." 4. "My son has been smoking marijuana and skipping school." 5. "I hope the new baby is a boy so he won't have the same illness." Answer: 1, 2, 3, 4 Explanation: 1. The parents of a child with a genetically transmitted disease may feel guilty. 2. Some children may feel angry toward the parent who carries the altered gene. 3. The parent or child may feel angry or depressed. 4. A child with a late-onset disease may be more likely to engage in risky and less socially acceptable behaviors. 5. Both males and females are equally affected with an autosomal dominant genetic disorder. Page Ref: 190 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Family Dynamics Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

42 ..

43) The manager determines that a new staff nurse is capable of caring for patients with genetic disorders. What information did the manager use to make this decision? Select all that apply. 1. The nurse evaluates care provided to patients. 2. The nurse identifies patients' needs for referrals. 3. The nurse advocates for pregnancy terminations. 4. The nurse performs physical assessments accurately and thoroughly. 5. The nurse consistently completes a genetic-focused family history with patients. Answer: 1, 2, 4, 5 Explanation: 1. Basic interventions that meet the standards of genetic nursing include evaluating care provided to patients. 2. Basic interventions that meet the standards of genetic nursing include identifying patients' needs for referrals. 3. The nurse should advocate for the patient based upon sound information and decisions. This does not include advocating for pregnancy terminations. 4. Basic interventions that meet the standards of genetic nursing include performing accurate and thorough physical assessments. 5. Basic interventions that meet the standards of genetic nursing include completing geneticfocused family histories with patients. Page Ref: 190 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

43 ..

44) The nurse is preparing information for a group of parents as part of genetic counseling. What basic principle of inheritance should the nurse include in this presentation? Select all that apply. 1. All genes are paired. 2. Only one gene is passed on to offspring. 3. The mother's genes are transmitted to offspring. 4. The father's genes are used to fill in genetic deficits in offspring. 5. One copy of a gene comes from the mother and the other copy from the father. Answer: 1, 2, 5 Explanation: 1. The basic underlying principles of inheritance that nurses can apply to inheritance risk assessment and teaching include that all genes are paired. 2. The basic underlying principles of inheritance that nurses can apply to inheritance risk assessment and teaching include that only one gene of each pair is transmitted (passed on) to an offspring. 3. Both parents' genes are transmitted to offspring. 4. The father's genes are not used to fill in genetic deficits in offspring. 5. The basic underlying principles of inheritance that nurses can apply to inheritance risk assessment and teaching include that one copy of each gene in the offspring comes from the mother and the other copy comes from the father. Page Ref: 184 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 8.2 Describe the principles of inheritance. MNL Learning Outcome: 2. Demonstrate understanding of the principles of inheritance.

44 ..

45) A patient pregnant with a first child needs genetic testing that will be partially covered by the health insurance plan. What should the nurse encourage the patient to consider before making a decision about the testing? Select all that apply. 1. Extended family members may resent the patient. 2. There might not be treatment available for the genetic disorder. 3. The patient may terminate the pregnancy before family is informed. 4. The patient must determine whether she is prepared for lifestyle alterations based upon the results. 5. The insurance company will have information about the genetic testing. Answer: 1, 2, 4, 5 Explanation: 1. Depending upon the results, family members may resent the patient for having a baby with a genetic disorder. 2. Depending upon the results, there might not be a treatment available for the disorder. 3. Termination of pregnancy is not something that should be discussed at this time. 4. The patient may or may not be able to care for the baby depending upon the genetic disorder. 5. Since the health plan does provide genetic testing coverage, the plan will have information about the testing. Page Ref: 190 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

45 ..

46) The nurse is concerned that a patient pregnant with a fetus with a genetic disorder is experiencing moral and ethical problems. What should the nurse offer to support the patient at this time? Select all that apply. 1. The patient's use of coping mechanisms 2. Actions to take to reduce stress and anxiety 3. Reasons for terminating the pregnancy at this time 4. Assistance with thinking through the process to increase optimism 5. Ask if the patient has any particular spiritual advisor that can be contacted Answer: 1, 2, 4, 5 Explanation: 1. Problems that a patient facing a genetic disorder may experience include spiritual distress, ineffective coping, anxiety, and powerlessness. The use of coping mechanisms helps with the problem of ineffective coping. 2. Problems that a patient facing a genetic disorder may experience include spiritual distress, ineffective coping, anxiety, and powerlessness. Actions to reduce stress and anxiety help with the problem of anxiety. 3. The nurse should help the patient with problem solving and not suggest termination of the pregnancy. 4. Problems that a patient facing a genetic disorder may experience include spiritual distress, ineffective coping, anxiety, and powerlessness. Assisting the patient to think through the process to increase optimism helps with the problem of powerlessness. 5. Problems that a patient facing a genetic disorder may experience include spiritual distress, ineffective coping, anxiety, and powerlessness. Asking about a spiritual advisor helps with the problem of spiritual distress. Page Ref: 191 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 4. Implement the nursing process to provide care to patients with a genetic disorder.

46 ..

47) At the conclusion of a health history and physical assessment, the nurse determines that a patient might benefit from genetic testing. What did the nurse assess to come to this conclusion? Select all that apply. 1. Infertility 2. Seizure disorder 3. Menopause at age 32 4. Neighbor committed suicide 5. Cousin addicted to heroin Answer: 1, 2, 3 Explanation: 1. Indications for a referral to a genetic specialist include infertility. 2. Indications for a referral to a genetic specialist include seizure disorder. 3. Indications for a referral to a genetic specialist include premature ovarian failure as might be seen with early menopause. 4. A neighbor's suicide is not an indication for a genetic specialist. 5. A cousin's drug addiction is not an indication for a genetic specialist. Page Ref: 192 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8.3 Describe the interprofessional care, nursing care, and transitions of care for patients with genetic disorders. MNL Learning Outcome: 3. Consider intraprofessional care for patients with a genetic disorder.

47 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 9 Nursing Care of Patients in Pain 1) The nurse is assessing a patient's response to pain. Why should the nurse do this for every patient situation? 1. Everyone has a unique tolerance to pain. 2. Everyone has the same pain threshold. 3. Everyone perceives painful stimuli at the same intensity. 4. Most people have the same pain response to surgery. Answer: 1 Explanation: 1. Each person's pain tolerance is different and will need to be assessed on an individual basis. 2. Everyone does not have the same pain threshold. 3. Everyone perceives pain at a different intensity. 4. Different people have a different pain response to surgery. Page Ref: 206 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Personal and Professional Development; Practice-Know-How; Apply decision making skills, particularly in the context of uncertainty and ambiguity | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

1 ..

2) After assessing a patient for pain, the nurse concludes that the pain is caused by a mechanical stimulus. What should the nurse consider as a possible cause of this patient's pain? 1. Muscle tear 2. Burn 3. Frostbite 4. Myocardial infarction Answer: 1 Explanation: 1. Mechanical causes of pain include spasm, compression, or extreme muscle stretch or contraction. A muscle tear creates pain from a mechanical source. 2. A burn involves pain from a thermal source. 3. Frostbite involves pain from a thermal source. 4. Myocardial infarction involves pain from a chemical source. Page Ref: 201 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.2 Describe the theories about, physiology of, pathways of, and modulation of pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

2 ..

3) The nurse is using the neuromatrix theory when determining a patient's pain. On what should the nurse focus when completing this assessment? 1. Cultural and genetic factors 2. Specificity 3. Pattern 4. Previous sensitization Answer: 1 Explanation: 1. The neuromatrix theory of pain integrates cultural and genetic factors with basic neurophysiological function. According to this theory, the brain contains a body-self neuromatrix, a widely distributed network of neurons that are affected by both genetic factors and sensory experiences. The neuromatrix integrates multiple sources of input in addition to the stimuli of pain and touch. Other sensory systems that help interpret the input, such as attention, expectation, personality, culture, innate pain modulation systems, and components of stress-regulation systems, all contribute to the pain experience for the individual. 2. Specificity theories describe nerve impulses of varying intensity terminating in pain centers in the forebrain. 3. Pattern theories describe nerve impulses of varying intensity terminating in pain centers in the forebrain. 4. According to the pain sensitization theory, painful signals create a cascade of changes in the nervous system, which increases the responsiveness of the peripheral and central neurons. These changes increase the response to future signals and amplify pain. Page Ref: 200 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.2 Describe the theories about, physiology of, pathways of, and modulation of pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

3 ..

4) A patient reports experiencing deep, burning pain. In which way is this patient's pain being transmitted in the body? 1. C fibers 2. A-delta fibers 3. Endorphins 4. Dynorphins Answer: 1 Explanation: 1. The pain from deep body structures, such as muscles and viscera, is primarily transmitted by C fibers, producing diffuse burning or aching sensations. 2. A-delta fibers are myelinated and transmit impulses rapidly. They produce what is called fast pain or first pain, which is sharp, well-defined pain typically accompanying cuts, electric shocks, or the impact of a blow. 3. Endorphins are endogenous opioids that block the transmission of painful impulses. 4. Dynorphins are endogenous opioids that block the transmission of painful impulses. Page Ref: 201 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.4. Assess presence and extent of pain and suffering | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.2 Describe the theories about, physiology of, pathways of, and modulation of pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

4 ..

5) A patient asks why pain was felt in the left arm during a myocardial infarction. How should the nurse respond? 1. "Pain in the arm related to cardiac tissue damage is a type of referred pain." 2. "Cardiac pain is generally unexplainable." 3. "Were you doing some physical activity with your arm just prior to the event?" 4. "What you are describing relates to psychogenic pain." Answer: 1 Explanation: 1. Referred pain is pain perceived in an area distant from the stimulus. Visceral sensory fibers synapse at the level of the spinal cord, close to fibers innervating other subcutaneous tissue areas of the body. 2. Cardiac pain is explainable. 3. Physical activity did not trigger the pain. 4. Psychogenic pain occurs in the absence of a diagnosed physiological cause or event. Page Ref: 203 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

5 ..

6) A patient is being treated for chronic pain. What should the nurse keep in mind when assessing this patient's level of pain? 1. The pain rating may be inconsistent with the underlying pathology. 2. There is usually a clear, physiologic cause. 3. Pain typically lasts 2 months or less. 4. The pain reported is usually less severe than acute pain. Answer: 1 Explanation: 1. The patient might not exhibit signs of pain such as elevations in vital signs, grimacing, writhing, or moaning. 2. There may not be an identified physiologic cause. 3. Chronic pain may persist for longer than 2 months. 4. There is no indication that chronic pain is less severe than acute pain, although in some instances it may be more diffuse. Page Ref: 204 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

6 ..

7) The nurse is managing care for a group of patients with pain. For which health problem should the nurse expect the patient to experience acute pain? 1. Cholecystectomy 2. Phantom limb pain 3. Complex regional pain syndrome 4. Degenerative joint disease Answer: 1 Explanation: 1. Acute pain has a sudden onset, is usually self-limited, and is localized. The cause of acute pain generally can be identified. It generally results from tissue injury from trauma, surgery, or inflammation. Surgical pain such as after gallbladder removal is considered acute pain. 2. The neuropathic pain associated with amputation, phantom limb pain, may not begin immediately and may become a chronic problem. 3. Complex regional pain syndrome is a chronic exaggerated response to a painful stimulus. 4. Degenerative joint disease is chronic; the accompanying joint pain is also chronic. Page Ref: 204 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

7 ..

8) The nurse is planning care for a patient with chronic pain. Which pain control goal would be most appropriate for this patient? 1. Reduce the focus on pain. 2. Reduce the sympathetic stress response. 3. Be completely pain-free. 4. Improve patient outcomes. Answer: 1 Explanation: 1. With chronic pain, the pain itself becomes the problem, creating physical, psychosocial, and economic stresses on the affected individual and the family. Furthermore, emotional and psychologic factors can cause the pain itself or make it worse. 2. Reducing the sympathetic pain response would be an appropriate acute pain management goal. 3. Being completely pain-free might be an unattainable goal for a patient with chronic pain. 4. Improving patient outcomes would be an appropriate acute pain management goal. Page Ref: 203 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

8 ..

9) A patient scheduled for knee surgery expects to experience less pain than what was experienced 20 years ago after a similar surgery. What should the nurse respond to this patient? 1. "There might be more pain, because the pain response can get worse with aging." 2. "You are most likely correct." 3. "It should not be quite as bad with the newer technology." 4. "Pain responses diminish with age." Answer: 1 Explanation: 1. Pain tolerance decreases with aging, perhaps related to the prevalence of chronic pain in this population. 2. The nurse should not agree that the patient will have less pain because this may not occur. 3. The amount of pain may or may not be impacted by the use of newer technology. 4. The pain response does not diminish with age. Page Ref: 206 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

9 ..

10) A female patient reports having pain so severe that it limits the ability to get out of bed at home. What should the nurse realize is contributing to this patient's pain? 1. Gender 2. Overuse of alcohol 3. Overuse of pain medication 4. Too much sleep and rest Answer: 1 Explanation: 1. The pain threshold is the point at which a stimulus elicits a response. Clinical and animal studies show that women have a lower pain threshold and experience a higher intensity of pain than men. 2. Alcohol may raise pain tolerance; however, there is no evidence that the patient is using alcohol. 3. Medications may raise pain tolerance. 4. Sleep and rest may raise pain tolerance. Page Ref: 206 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

10 ..

11) A patient with depression reports having unrelenting pain over the last several weeks. What should the nurse consider as contributing to this patient's amount of pain? 1. Depression can cause an increase in pain sensations. 2. The pain medication has not been working. 3. Medication to treat the depression is interfering with the control of pain. 4. The patient is exaggerating the amount of pain. Answer: 1 Explanation: 1. Depression is clearly linked to pain. Serotonin, a neurotransmitter, is involved in the modulation of pain in the central nervous system. In clinically depressed people, serotonin is decreased, leading to an increase in pain sensations. 2. The nurse has no way of knowing if the patient's pain medication is not controlling the pain. 3. There is also no way of knowing if the medication used to treat the patient's depression is interfering with the control of pain. 4. The nurse cannot assume that the patient is exaggerating the amount of pain. Page Ref: 207 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

11 ..

12) A patient reports the inability to sleep through the night because of leg pain. What will the nurse most likely assess in this patient? 1. An increase in pain 2. A decrease in pain 3. A decrease in anxiety 4. An increase in concentration Answer: 1 Explanation: 1. Pain interferes with a person's ability to fall asleep and stay asleep and can induce fatigue. Fatigue can lower pain tolerance. The nurse will most likely assess an increase in pain in the patient who is unable to sleep. 2. There will not be a decrease in pain. 3. Anxiety may increase the perception of pain, and pain may cause more anxiety. 4. The patient in pain often has difficulty concentrating. Page Ref: 207 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

12 ..

13) The nurse is caring for a patient recovering from surgery. Which intervention will provide the most pain relief for the patient? 1. Offer pain relief before the patient complains of pain. 2. Wait until the patient can describe the pain specifically. 3. Assess the pain level every 4 hours around the clock. 4. Allow the patient to "sleep off" the anesthesia, then offer pain medication. Answer: 1 Explanation: 1. Anticipating a patient's pain will ensure a more manageable pain experience than will waiting until the patient complains of pain. 2. Pain management needs to be implemented before the patient describes specific postoperative pain. 3. The patient should not be awakened to assess pain unless there are other significant nonverbal signs during sleep that indicate the patient is in pain. These can include grimacing, moaning, thrashing, or guarding of a surgical site. 4. Pain management needs to be implemented before the patient "sleeps off" anesthesia. Page Ref: 222 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

13 ..

14) A patient with severe nerve pain from spinal cord compression is considering surgery to sever the nerves and relieve the pain. What should the nurse encourage the patient to consider prior to having this surgery? 1. There may be loss of motor function associated with the nerves that will be severed. 2. The surgery will need to be repeated when the nerves regenerate. 3. Pain medication will still be needed after the surgery. 4. The patient will be a paraplegic after the surgery. Answer: 1 Explanation: 1. Motor function loss is an unwelcome side effect of some surgeries, so the patient needs to consider the amount and degree of potential motor loss. 2. The nerves will not regenerate, so surgery will not need to be repeated. 3. Pain medication may or may not be needed after the surgery. 4. Not all surgeries to sever nerves to control pain result in paraplegia. Page Ref: 214 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain.

14 ..

15) A patient with chronic orthopedic pain is considering the use of a transcutaneous electrical nerve stimulator to reduce the pain. What advantage of using this device should the nurse review with the patient? 1. Avoids the adverse effects of pain medication 2. Is low in cost 3. Can be used by all patients 4. Can relieve all types of pain Answer: 1 Explanation: 1. A transcutaneous electrical nerve stimulator has the advantages of avoidance of adverse drug effects, patient control, and good interaction with other therapies. 2. Disadvantages of this device are the cost and the need for expert training. 3. This device is not effective at relieving pain for all patients. Patients with pacemakers should not use this device. 4. This device is not effective at relieving all types of pain. Page Ref: 216 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-KnowHow; Communicate information effectively; listen openly and cooperatively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain.

15 ..

16) A patient is watching a comedy on the television and has not requested pain medication for over 6 hours. Which form of pain control is this patient using? 1. Distraction 2. Meditation 3. Guided imagery 4. Biofeedback Answer: 1 Explanation: 1. Distraction involves redirecting attention away from the pain and onto something the patient finds more pleasant. Participating in an activity that promotes laughter has been found to be highly effective in pain relief. Laughing for 20 minutes or more is known to produce an increase in endorphins that may continue to relieve pain even after the patient stops laughing. 2. Meditation is a process of emptying the mind of all sensory data and, typically, concentrating on a single object, word, or idea. This activity produces a deeply relaxed state in which oxygen consumption decreases, muscles relax, and endorphins are produced. 3. Guided imagery is use of the mind to create a scene or sensory experience that relaxes the muscles and moves the attention away from the pain experience. 4. In biofeedback, electrodes placed on the skin transform data into visual cues so the patient learns to recognize stress-related responses and replace them with relaxation responses. Page Ref: 216 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

16 ..

17) A patient is receiving a narcotic for severe acute pain. What should the nurse encourage the patient to consume in greater quantities due to the pain medication? 1. Fiber 2. Vitamin D 3. Protein 4. Carbohydrates Answer: 1 Explanation: 1. Patients receiving narcotics are at risk for constipation. Increasing fiber in the diet will help to reduce this effect. 2. Increasing vitamin D is not specifically related to the effects of a narcotic medication. 3. Increasing protein is not specifically related to the effects of a narcotic medication. 4. Increasing carbohydrates is not specifically related to the effects of a narcotic medication. Page Ref: 212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain.

17 ..

18) A patient who is 2 hours postoperative following bowel resection surgery has four standing orders for pain medication. Which medication should the nurse consider providing to the patient for pain? 1. The one that is to be administered intravenously by the patient and is under patient control. 2. The one that will be given intramuscularly to work quickly. 3. The one that is ordered on a prn basis. 4. The one to be administered orally. Answer: 1 Explanation: 1. Patient-controlled analgesia allows self-management of pain and is a common method of administering postoperative pain medication. The advantages to this method are dose precision, timeliness, and convenience. 2. The medication that is administered intramuscularly is not typically recommended for moderate-to-severe pain that will require more than one dose. 3. A prn medication administered 2 hours after a major surgery would not be the most effective. 4. An oral medication administered 2 hours after a major surgery would not be the most effective. Page Ref: 214 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain.

18 ..

19) A patient recovering from abdominal surgery is refusing pain medication because of the fear of becoming addicted even though pain is rated as 10 out of 10. What statement should the nurse include as part of the patient's education? Select all that apply. 1. There is little to no risk of addiction when taking narcotics for pain. 2. Untreated pain can result in poor wound healing. 3. Patients with uncontrolled pain can develop altered immune function. 4. Dehydration can result from poorly managed pain. 5. Family members will not want to visit patients showing visible signs of pain. Answer: 1, 2, 3 Explanation: 1. A common myth among healthcare professionals is that using opioids for pain treatment poses a real threat of addiction. Actually, when the medications are used as recommended, there is little to no risk of addiction. 2. Pain causes physiological consequences, including poor wound healing. 3. Pain causes physiological consequences, including altered immune function. 4. There is no evidence that poor pain relief causes dehydration. 5. There is no evidence that poor pain relief causes family members to refuse to visit. Page Ref: 199 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.1 Define pain; why it is called the fifth vital sign, the adverse effects of it, and myths and misconceptions about it. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

19 ..

20) A patient refusing to take pain medication for chronic back pain is asked to rate the pain on a scale from 0 to 10. What is the nurse attempting to do with this patient? 1. Assess the patient's level of pain 2. Determine if the patient should remain in the hospital 3. Decide if the patient is being argumentative 4. Figure out if the patient should leave the hospital against medical advice Answer: 1 Explanation: 1. The most reliable indicator of the presence and degree of pain is the patient's own statements about the pain. Pain rating scales ensure consistent communication about the pain level. 2. The nurse is not attempting to question the patient's admission or stay in the hospital. 3. The nurse is not attempting to decide if the patient is being argumentative. 4. The nurse is not attempting to decide whether the patient should leave the hospital against medical advice. Page Ref: 218 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

20 ..

21) The nurse is assessing a patient's vital signs. What should the nurse include in this assessment? 1. Peripheral pulses 2. Pain level 3. Ability to ambulate 4. Urine output Answer: 2 Explanation: 1. Assessment of peripheral pulses is done to check for presence and strength; it is not routinely done to assess a pulse rate. 2. Pain is increasingly being referred to as the "fifth vital sign," with recommendations to include pain assessment in every vital signs assessment. 3. Ambulation is not a vital sign. 4. Urine output is not a vital sign. Page Ref: 199 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.1 Define pain; why it is called the fifth vital sign, the adverse effects of it, and myths and misconceptions about it. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

21 ..

22) The patient complaining of pain has been waiting for medication to relieve the pain. What should the nurse understand about this patient? 1. The patient's pain is real. 2. The patient just wants medication. 3. The patient wants attention. 4. The patient is demanding. Answer: 1 Explanation: 1. If the patient says he or she has pain, the patient is in pain. All pain is real. 2. Nurses should not be judgmental when responding to a patient's report of pain. This is a common bias and is a barrier to effective pain management. 3. This is the nurse's interpretation. 4. This is the nurse's interpretation. Page Ref: 199 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.1 Define pain; why it is called the fifth vital sign, the adverse effects of it, and myths and misconceptions about it. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

22 ..

23) A patient with a history of chronic pain reports doing things to help the body make a natural pain reliever. What should the nurse realize this patient is describing? 1. A theory of denial 2. A belief in alternative methods 3. A reason to reduce the amount of pain medication prescribed 4. The body's ability to make endorphins Answer: 4 Explanation: 1. The patient is not denying the pain. 2. Alternative methods have not been employed. 3. There was no discussion of pain medication amounts. 4. There is a pain inhibitory center within the dorsal horns of the spinal cord. The exact nature of this inhibitory mechanism is unknown. However, the most clearly defined chemical inhibitory mechanism is fueled by endorphins (endogenous opioids), which are naturally occurring morphine-like peptides that are present in neurons in the brain, spinal cord, and gastrointestinal tract. Endorphins work by binding with opiate receptors on the neurons to inhibit pain impulse transmission. Page Ref: 202 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.2 Describe the theories about, physiology of, pathways of, and modulation of pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

23 ..

24) A patient has a history of scoliosis and back pain. For which type of pain should the nurse plan care for this patient? 1. Recurrent acute pain 2. Ongoing time-limited pain 3. Chronic malignant pain 4. Chronic nonmalignant pain Answer: 4 Explanation: 1. Recurrent acute pain is characterized by relatively well-defined episodes of pain interspersed with pain-free episodes. 2. Ongoing time-limited pain is not a commonly used term for pain. 3. Malignancy is not mentioned as a cause of the pain. 4. Chronic nonmalignant pain is non-life-threatening pain that nevertheless persists beyond the expected time for healing. Chronic lower back pain falls into this category. Page Ref: 204 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

24 ..

25) A patient with a history of lumbar spinal cord nerve compression continues to complain of burning pain. Which type of pain should the nurse realize this patient is experiencing? 1. Complex regional pain syndrome 2. Myofascial pain syndrome 3. Chronic postoperative pain 4. Phantom limb pain Answer: 1 Explanation: 1. Complex regional pain syndrome is a neuropathic pain that results from nerve damage. It is characterized by continuous severe, burning pain. These conditions follow peripheral nerve damage and present the symptoms of pain, vasospasm, muscle wasting, and vasomotor changes. 2. Myofascial pain syndrome is a condition marked by injury to or disease of muscle and fascial tissue. 3. This pain was not described as chronic. 4. No amputation has been performed that might explain phantom limb pain. Page Ref: 205 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

25 ..

26) A patient with a long history of pain rarely appears to be in pain and often forgoes the use of pain medication. What does the nurse realize about this patient? 1. The patient has a high pain tolerance. 2. The patient has a low pain tolerance. 3. The patient is addicted to pain medication. 4. The patient does not really have pain. Answer: 1 Explanation: 1. Pain tolerance describes the amount of pain a person can tolerate before outwardly responding to it. A patient with a high tolerance to pain would rarely report pain or need analgesic management. 2. With a low tolerance, the patient would be verbalizing pain and requesting medication. 3. If addicted, the patient would eventually need more medication, not less, to manage the pain. 4. There is no evidence that the patient is not in pain. Page Ref: 206 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

26 ..

27) A patient with chronic pain reports rarely sleeping more than 3 hours a night. Which health problem is this patient at risk for developing? 1. Chronic insomnia 2. Depression 3. High pain tolerance 4. Adult attention deficit disorder Answer: 2 Explanation: 1. There is no evidence to support the risk of chronic insomnia, although insomnia is associated with chronic pain. 2. Depression is clearly linked to pain, and insomnia is an associated symptom of chronic pain. Serotonin, a neurotransmitter, is involved in the modulation of pain in the central nervous system. In clinically depressed people, serotonin is decreased, which leads to an increase in pain sensations. 3. There is no evidence to support inferences concerning pain tolerance. 4. There is no evidence to support the risk of adult attention deficit disorder. Page Ref: 207 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

27 ..

28) A patient with chronic pain is desperately searching for something to relieve the pain. What should the nurse recommend for this patient? 1. A thorough analysis of the pain to determine if it is truly pain 2. Avoiding the use of narcotics 3. Evaluation by a psychiatrist to determine if the patient is depressed 4. A pain medication schedule to help avoid the onset of pain Answer: 4 Explanation: 1. The pain has already been identified as being real and chronic in nature. 2. Avoidance of narcotics may not meet the patient's immediate needs. 3. There is no mention of a depressed state, only the patient's need to address the pain. 4. It is now widely accepted that anticipating pain has a noticeable effect on the amount of pain a patient experiences. Offering pain relief before a pain event is well on its way can lessen the pain. Page Ref: 212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

28 ..

29) A patient has periodic severe nerve pain that is not well controlled with pain medication. Which pain management approach should be considered for this patient? 1. A nonsteroidal anti-inflammatory drug (NSAID) 2. A narcotic 3. An antidepressant 4. A local anesthetic Answer: 3 Explanation: 1. The NSAID group can have serious side effects, including bleeding tendencies, and would not be appropriate in a long-term situation. 2. Other medications are prescribed before introducing narcotics. 3. Antidepressants within the tricyclic and related chemical groups act on the production and retention of serotonin in the CNS, thus inhibiting pain sensation. They also promote normal sleeping patterns, which further alleviates the suffering of the patient in pain. They are useful with neuropathic pain. 4. A local anesthetic would not be appropriate for long-term pain management. Page Ref: 212 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain.

29 ..

30) A patient who is receiving around-the-clock pain medication complains of an acute exacerbation of pain. What should the nurse do to help this patient? 1. Provide the medication prescribed for breakthrough pain. 2. Talk with the patient through the pain. 3. Encourage the patient to ignore the pain. 4. Give the patient a nonsteroidal anti-inflammatory drug (NSAID). Answer: 1 Explanation: 1. Breakthrough pain (BTP) occurs in patients who are receiving long-acting analgesics for chronic pain. It is a transitory experience of moderate to severe pain that is often precipitated by coughing or movement but may occur spontaneously. Short-acting opioids for this type of pain should be administered as needed in addition to the ATC dose for chronic, persistent pain. 2. The pain must be addressed; it is not appropriate to talk with the patient through the pain. 3. The pain must be addressed; it is not appropriate to encourage the patient to ignore the pain. 4. NSAIDs can only be given with the physician's order. Page Ref: 213 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

30 ..

31) A patient with chronic pain is being started on a "patch." What should the nurse instruct the patient about this pain-relieving delivery system? 1. It will not work as well as oral pain medications. 2. The dosage will be lower in the beginning. 3. The patient will never experience breakthrough pain. 4. The patient will never overdose with this delivery method. Answer: 2 Explanation: 1. The transdermal, or patch, form of medication is increasingly being used because it is simple, painless, and delivers a continuous level of medication. The continuous dosage is an advantage over oral medications. Transdermal medications are easy to store and apply, and reapplying every 72 hours enhances compliance. 2. Dosages for the "patch" start low and are increased as deemed necessary by the healthcare provider. 3. Additional short-acting medication is often needed for breakthrough pain. 4. Overdosage can occur with this route. Page Ref: 213 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-KnowHow; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

31 ..

32) The nurse is helping a patient in pain by gently massaging the painful area. Which type of pain control is the nurse using? 1. Acupuncture 2. Biofeedback 3. Guided imagery 4. Cutaneous stimulation Answer: 4 Explanation: 1. There is no mention of the use of acupuncture needles. 2. Biofeedback does not involve massage. 3. Guided imagery does not involve massage. 4. Cutaneous stimulation is a nonpharmacological approach to pain management that may be accomplished by massage, vibration, applying heat and cold, and therapeutic touch. Page Ref: 221 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

32 ..

33) The nurse plans to assess a patient's pain perception. What should the nurse use for this assessment? 1. FACES scale 2. Psychological evaluation tool 3. PQRST guide 4. Biofeedback rating Answer: 3 Explanation: 1. The FACES scale is a pain-rating tool. 2. Use of a psychological evaluation tool is not indicated. 3. A patient's pain perception can be assessed by using the PQRST technique: P = What precipitated (triggered, stimulated) the pain? Has anything relieved the pain? What is the pattern of the pain? Q = What is the quality and quantity of the pain? Is it sharp, stabbing, aching, burning, stinging, deep, crushing, viselike, or gnawing? R = What is the region (location) of the pain? Does the pain radiate to other areas of the body? S = What is the severity of the pain? And T = What is the timing of the pain? When does it begin, how long does it last, and how is it related to other events in the patient's life? 4. A biofeedback rating would not address all areas of a pain assessment. Page Ref: 217 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

33 ..

34) A patient is seen talking and laughing in the clinic's waiting room yet complains of excruciating pain. What should the nurse realize this patient is demonstrating? 1. The desire for narcotics 2. Denial 3. Fake pain 4. Inconsistent behavioral response to pain Answer: 4 Explanation: 1. No mention is made of the patient requesting narcotics. 2. Behavioral responses to pain may or may not coincide with the patient's report of pain and are not very reliable cues to the pain experience. 3. The nurse cannot decide if the patient's pain is real. 4. Behavioral responses to pain may or may not coincide with the patient's report of pain and are not very reliable cues to the pain experience. The nurse needs to manage the pain if the patient verbalizes that it is present, even if the nonverbal signs are not congruent. Page Ref: 219 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Sensory/Perceptual Alterations Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

34 ..

35) A patient receiving morphine sulfate 10 mg intramuscularly every 4 hours is being switched to an oral dose. Calculate the oral dosage range using the equianalgesic dosing formula: ________ mg. Record your answer rounding to the nearest whole number, using a dash ("-") to indicate the range. Answer: 30-60 Explanation: The oral dose is 3 to 6 times the IM dose. Page Ref: 210 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain. 36) A patient is prescribed a fentanyl patch to administer 100 mcg/hour, uses one patch for 72 hours, and then is changed to an intravenous infusion of morphine 8 hours into the second patch. How many mg of the medication did the patient receive while wearing the patch? Record your answer rounding to the nearest whole number. Answer: 320 mg Explanation: Fentanyl 100 mcg/hr is equivalent to 4 mg/hr morphine IV. If the first patch was for 72 hours and the second patch was for 8 hours, the patient wore the patch for a total of 80 hours. Multiply the equivalent dose of 4 mg × 80 = 320 mg. Page Ref: 210 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 2. Consider intraprofessional care for patients in pain.

35 ..

37) The nurse is ranking a patient's prescribed pain medications according to their strengths. Using the WHO analgesic ladder, in what order, from weakest to strongest, should the nurse rank the medications? Choice 1. Morphine sulfate 5 mg IV Choice 2. Ibuprofen 400 mg PO with the anticonvulsant gabapentin (Neurontin) 300 mg PO Choice 3. Propoxyphene HCL (Darvon) 250 mg PO Choice 4. Acetaminophen (Tylenol) 325 mg PO Answer: 4, 2, 3, 1 Explanation: Choice 1. Morphine is the strongest of these pain medications. It is an opioid. Choice 2. Ibuprofen is a nonopioid and is the second weakest of these medications. Choice 3. Propoxyphene is the second strongest of these medications. Choice 4. Tylenol is the weakest of these medications. Page Ref: 208 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

36 ..

38) The nurse is explaining the pain response process to a patient experiencing chronic pain. In which order should the nurse identify the steps in the neural pain pathway? Place in order the steps of the process. Choice 1. In the thalamus and cerebral cortex, the pain impulse becomes pain when the sensation reaches conscious levels and is perceived and evaluated by the person experiencing the sensation. Choice 2. Dorsal horn synapses relay impulses up the spinal cord. Spinal neurons transmit the impulses via axons that cross over to the spinothalamic tract. Choice 3. The impulses ascend the spinothalamic tracts and pass through the medulla and midbrain to the thalamus. Choice 4. A noxious stimulus is perceived by cutaneous nociceptors and then transmitted through A-delta (AΔ) and even smaller C nerve fibers to the spinal cord dorsal horn. Answer: 4, 2, 3, 1 Explanation: Choice 1. This is the final step in the neural pain pathway. Choice 2. This is the second step in the neural pain pathway. Choice 3. This is the third step in the neural pain pathway. Choice 4. This is the first step in the neural pain pathway. Page Ref: 201-202 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.2 Describe the theories about, physiology of, pathways of, and modulation of pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

37 ..

39) The nurse is preparing to apply a transdermal analgesic patch to a patient. In what order should the nurse administer this medication? Place in order the steps of the process. Choice 1. Choose a new site and cleanse and dry an upper torso location. Choice 2. Clip chest hair and open the medication package. Choice 3. Keep the patch intact for 72 hours. Choice 4. Place the patch, making sure all edges are in contact with the skin. Answer: 1, 2, 4, 3 Explanation: Choice 1. A transdermal patch is applied to a clean, dry area on the upper torso. Choice 2. If hair is present, it should be clipped before applying the patch. Choice 3. The patch is effective for about 72 hours. Choice 4. Apply the patch immediately after opening the package, ensuring complete contact with the skin, especially around the edges. Page Ref: 213 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

38 ..

40) A homebound hospice patient receiving opioid pain medication continues to experience pain. Which nonpharmacologic complementary methods should the nurse instruct the patient? Select all that apply. 1. Guided imagery 2. Progressive muscle relaxation 3. Distraction 4. Acupuncture 5. Regional pain management Answer: 1, 2, 3 Explanation: 1. Guided imagery can be taught to the patient by the nurse. 2. Progressive muscle relaxation can be taught to the patient by the nurse. 3. Distraction can be taught to the patient by the nurse. 4. Acupuncture cannot be taught to the patient by the nurse. Acupuncture can only be provided by persons with special training. 5. Regional pain management is not an alternative complementary therapy. Page Ref: 216-217 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

39 ..

41) The nurse is caring for older patients in a long-term-care facility. Which factor should the nurse consider when managing pain in these patients? Select all that apply. 1. Increased A fiber transmission increases the potential for addiction in older adults. 2. An increased risk of depression in older adults is related to chronic pain. 3. Less reporting of referred pain may mask myocardial infarction in older adults. 4. Assessment of pain in the cognitively impaired older adult is not possible. 5. Delirium should be evaluated as pain. Answer: 2, 3, 5 Explanation: 1. There is actually decreased fiber transmission and no greater risk of dependence with older adults. 2. There is an increased risk of depression in the older patient experiencing chronic pain. 3. Older adults are less likely to report referred pain, meaning they may present in a different manner than younger adults. This may lead to problems diagnosing patients appropriately. 4. Research has shown the numeric rating, verbal descriptor, and FACES rating scales to be effective with older adults. These scales are also effective with cognitively impaired older adults, although the FACES scale is the preferred tool. 5. The older adult may present with manifestations such as delirium rather than subjective reports of pain. Page Ref: 206 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.4 Outline factors affecting responses to pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

40 ..

42) A patient recovering from a broken leg asks why the pain is so sharp. What should the nurse explain about acute pain? Select all that apply. 1. The pain signal releases catecholamines. 2. The pain signal reduces blood flow to the gut. 3. The pain signal travels along nerve fibers to the spinal cord. 4. The pain signal travels up to the brain portion called the thalamus. 5. The pain signal spreads throughout the cortex, limbic system, and brainstem. Answer: 3, 4, 5 Explanation: 1. The release of catecholamines explains the cardiovascular response to pain. 2. The reduction of blood flow to the gut explains why nausea and vomiting occur with pain. 3. With sharp local pain, nociceptors transmit pain stimuli along myelinated fibers to the spinal cord. 4. With sharp local pain, nociceptors transmit pain stimuli along myelinated fibers to the spinal cord, where it travels via the neospinothalamic tract to the thalamus. 5. With sharp local pain, the stimulus is distributed from the thalamus to the somatosensory cortex (perception and interpretation), the limbic system (emotional responses to pain), and brainstem centers (autonomic nervous system responses). Page Ref: 201-202 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-KnowHow; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9.2 Describe the theories about, physiology of, pathways of, and modulation of pain. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients in pain.

41 ..

43) A patient with bone pain complains that the pain is more intense when being repositioned in bed. For which type of pain should the nurse plan care? 1. Central 2. Incident 3. Nociceptive 4. Neuropathic Answer: 2 Explanation: 1. Central pain is caused by a lesion or damage in the brain or spinal cord. 2. Incident or episodic pain is predictable, precipitated by an event or activity such as coughing, changing position, or being touched. 3. Nociceptive pain is caused by stimulation of peripheral or visceral pain receptors. 4. Neuropathic pain arises as a consequence of a lesion or disease affecting the somatosensory system. Page Ref: 205 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 9.3 Differentiate definitions and characteristics of acute, chronic, breakthrough, nociceptive, and neuropathic pain. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients in pain.

42 ..

44) After completing an assessment, the nurse determines that a patient experiencing pain should avoid taking NSAIDs. What information caused the nurse to make this determination? Select all that apply. 1. The patient takes medication for peptic ulcer disease. 2. The patient has a pacemaker inserted for atrial fibrillation. 3. The patient had a total hip and total knee replacement a year ago. 4. The patient takes medication and vitamin K for a clotting disorder. 5. The patient performs peritoneal self-dialysis for chronic kidney failure. Answer: 1, 4, 5 Explanation: 1. NSAIDs are not recommended for use in people with peptic ulcer disease. 2. A pacemaker would not be a contraindication for using NSAIDs. 3. Total joint replacements are not a reason to contraindicate NSAIDs. 4. NSAIDs are not recommended for use in people with bleeding disorders. 5. NSAIDs are not recommended for use in people with kidney or liver disease. Page Ref: 208 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

43 ..

45) A patient with chronic pain is prescribed an anticonvulsant medication. What should the nurse instruct the patient to expect when taking this medication? Select all that apply. 1. Less nausea 2. Reduced pain 3. Improved sleep 4. Improved mobility 5. Reduced urine output Answer: 2, 3 Explanation: 1. Anticonvulsants are not prescribed to reduce nausea. 2. Anticonvulsants are frequently used with opioids in pain control because these drugs reduce pain. 3. Anticonvulsants are frequently used with opioids in pain control because these drugs reduce sleep disruption. 4. Anticonvulsants are not prescribed to improve mobility. 5. Anticonvulsants should not adversely affect renal functioning. Page Ref: 212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; PracticeKnow-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

44 ..

46) A patient is prescribed hydrocodone (Vicodin) for severe tooth pain. What should the nurse instruct the patient about taking this mediation? Select all that apply. 1. Avoid all alcohol. 2. Do not operate machinery. 3. Expect some respiratory depression. 4. Increase the intake of fluids and fiber. 5. Do not take with over-the-counter medications. Answer: 1, 2, 4, 5 Explanation: 1. The nurse should instruct the patient to avoid drinking alcohol while taking this medication. 2. The nurse should instruct the patient to use caution or avoid driving when taking this medication. 3. Respiratory depression can occur when taking this medication; however, it is not an expected effect and should be reported to the healthcare provider. 4. The nurse should instruct the patient to increase the intake of fluids and fiber to prevent constipation. 5. The nurse should instruct the patient not to take over-the-counter medications unless approved by the healthcare provider. Page Ref: 212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; PracticeKnow-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 9.5 Describe interprofessional care, nursing care, and transitions of care for patients in pain. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients in pain.

45 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 10 Nursing Care of Patients with Altered Fluid, Electrolyte, and Acid-Base Balance 1) The nurse is caring for an older patient who is occasionally confused. What should be the nurse's primary concern regarding fluid and electrolytes when caring for this patient? 1. Risk of dehydration 2. Risk of kidney damage 3. Risk of stroke 4. Risk of bleeding Answer: 1 Explanation: 1. As an adult ages, the thirst mechanism declines. In a patient with an altered level of consciousness, this presents an increased risk of dehydration and high serum osmolality. 2. The risks for kidney damage are not specifically related to aging or fluid and electrolyte issues. 3. The risk of stroke is not specifically related to aging or fluid and electrolyte issues. 4. The risk of bleeding is not specifically related to aging or fluid and electrolyte issues. Page Ref: 232 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.1 Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

1 ..

2) The nurse is planning care for a patient with severe burns. What health problem should the nurse realize that this patient could develop? 1. Intracellular fluid deficit 2. Intracellular fluid overload 3. Extracellular fluid deficit 4. Interstitial fluid deficit Answer: 1 Explanation: 1. Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. 2. The intracellular fluid is composed of all fluids that exist within the cell cytoplasm and nucleus. Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. 3. The extracellular fluid is composed of all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. 4. The extracellular fluid is composed of all fluids that exist outside the cell, including the interstitial fluid between the cells. Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Page Ref: 235 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

2 ..

3) A patient experiencing multisystem fluid volume deficit has tachycardia; pale, cool skin; and decreased urine output. Which process should the nurse consider is causing these findings? 1. The body's natural compensatory mechanisms 2. Pharmacological effects of a diuretic 3. Effects of rapidly infused intravenous fluids 4. Cardiac failure Answer: 1 Explanation: 1. The internal vasoconstrictive compensatory reactions within the body are responsible for the symptoms exhibited. The body naturally attempts to conserve fluid internally specifically for the brain and heart. 2. No evidence is provided that the patient received a diuretic. 3. Rapidly infused intravenous fluids would not cause a decrease in urine output. 4. The manifestations are not associated with cardiac failure. Page Ref: 235 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

3 ..

4) A pregnant patient is admitted with excessive thirst and increased urination. For which problem should the nurse focus the care of this patient? 1. Imbalanced fluid 2. Fluid overload 3. Nutritional deficiency 4. Insufficient blood flow Answer: 1 Explanation: 1. The patient with excessive thirst and increased urination is losing fluid. This is the problem on which the nurse should focus with this patient. 2. There is no evidence that the patient has an overabundance of fluid. 3. There is no evidence that the patient has a nutritional deficiency. 4. There is no evidence that this patient has insufficient blood flow. Page Ref: 232 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.1 Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

4 ..

5) A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volume should the nurse notify the patient's healthcare provider? 1. 600 mL 2. 750 mL 3. 1000 mL 4. 1200 mL Answer: 1 Explanation: 1. A urine output of less than 30 mL per hour must be reported to the primary healthcare provider. This indicates inadequate renal perfusion, placing the patient at increased risk for acute renal failure and inadequate tissue perfusion. A minimum of 720 mL over a 24hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours). 2. There is no reason to report this volume to the healthcare provider. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours). 3. There is no reason to report this volume to the healthcare provider. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours). 4. There is no reason to report this volume to the healthcare provider. A minimum of 720 mL over a 24-hour period is desired (30 mL multiplied by 24 hours equals 720 mL per 24 hours). Page Ref: 238 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

5 ..

6) A patient is receiving intravenous fluids postoperatively following cardiac surgery. On which potential postoperative complication should the nurse focus the assessment of this patient? 1. Fluid volume excess 2. Fluid volume deficit 3. Seizure activity 4. Liver failure Answer: 1 Explanation: 1. Antidiuretic hormone and aldosterone levels are commonly increased following the stress response before, during, and immediately after surgery. This increase leads to sodium and water retention. Adding more fluids intravenously can cause a fluid volume excess and stress upon the heart and circulatory system. 2. Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, and stress upon the heart and circulatory system. 3. Seizure activity would more commonly be associated with electrolyte imbalances. 4. Liver failure is not anticipated related to postoperative intravenous fluid administration. Page Ref: 240 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

6 ..

7) A patient is diagnosed with severe hyponatremia. Which type of precautions should be implemented for this patient? 1. Seizure 2. Infection 3. Neutropenia 4. High-risk fall Answer: 1 Explanation: 1. Severe hyponatremia can lead to seizures. Seizure precautions such as a quiet environment, raised side rails, and having an oral airway at the bedside would be included. 2. Infection precautions are not specifically indicated for a patient with hyponatremia. 3. Neutropenic precautions are not specifically indicated for a patient with hyponatremia. 4. High-risk fall precautions are not specifically indicated for a patient with hyponatremia. Page Ref: 246 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

7 ..

8) A patient is diagnosed with hypokalemia. Which medication should the nurse consider that might have contributed to the patient's health problem? 1. Corticosteroid 2. Thiazide diuretic 3. Narcotic 4. Muscle relaxant Answer: 1 Explanation: 1. Excess potassium loss through the kidneys is often caused by such medications as corticosteroids, potassium-wasting diuretics, amphotericin B, and large doses of some antibiotics. 2. Excessive sodium is lost with the use of thiazide diuretics. 3. Narcotics do not typically affect electrolyte balance. 4. Muscle relaxants do not typically affect electrolyte balance. Page Ref: 248 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

8 ..

9) A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. Of which electrolyte imbalance is this patient demonstrating signs? 1. Hyperkalemia 2. Hypokalemia 3. Hypercalcemia 4. Hypocalcemia Answer: 1 Explanation: 1. Hyperkalemia is serum potassium level greater than 5.3 mEq/L. Decreased potassium excretion is seen in potassium-sparing diuretics such as spironolactone. Common manifestations of hyperkalemia are muscle weakness and ECG changes. 2. Hypokalemia is seen in non-potassium sparing diuretics such as furosemide. 3. Hypercalcemia has been associated with thiazide diuretics. 4. Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use. Page Ref: 252 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

9 ..

10) The nurse is planning care for a patient with fluid volume overload and hyponatremia. What should be included in this patient's plan of care? 1. Restrict fluids. 2. Administer intravenous fluids. 3. Provide Kayexalate. 4. Administer intravenous normal saline with furosemide. Answer: 1 Explanation: 1. The nursing care for a patient with hyponatremia is dependent on the cause. Restriction of fluids is usually implemented to assist sodium increase and to prevent the sodium level from dropping further due to dilution. 2. The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia. 3. Kayexalate is used in patients with hyperkalemia. 4. The administration of normal saline with furosemide is used to increase calcium secretion. Page Ref: 245 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

10 ..

11) The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessment should the nurse include when caring for this patient? 1. Other electrolyte disturbances 2. Hypertension 3. Visual disturbances 4. Drug toxicity Answer: 1 Explanation: 1. The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. 2. The patient with hypocalcemia may exhibit hypotension, and not hypertension. 3. Visual disturbances do not occur with hypocalcemia. 4. Hypercalcemia is more commonly caused by drug toxicities. Page Ref: 257 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

11 ..

12) A patient with a history of stomach ulcers is diagnosed with hypophosphatemia. What intervention should the nurse include in this patient's plan of care? 1. Request a dietitian consult for selecting foods high in phosphorous. 2. Provide aluminum hydroxide antacids as prescribed. 3. Instruct patient to avoid poultry, peanuts, and seeds. 4. Instruct patient to avoid the intake of sodium phosphate. Answer: 1 Explanation: 1. Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet. 2. Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. 3. Poultry, peanuts, and seeds are part of a high phosphate diet. 4. Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate. Page Ref: 212 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

12 ..

13) The nurse is analyzing an arterial blood gas report of a patient with COPD and respiratory acidosis. Through which mechanism should the nurse expect compensation to occur? 1. The kidneys retain bicarbonate. 2. The kidneys excrete bicarbonate. 3. The lungs will retain carbon dioxide. 4. The lungs will excrete carbon dioxide. Answer: 1 Explanation: 1. The kidneys will compensate for a respiratory disorder by retaining bicarbonate. 2. Excreting bicarbonate causes acidosis to develop. 3. Retaining carbon dioxide causes respiratory acidosis. 4. Excreting carbon dioxide causes respiratory alkalosis. Page Ref: 266 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acidbase balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

13 ..

14) The nurse is caring for a patient diagnosed with renal failure. What should the nurse recognize as compensation for the acid‒base disturbance found in patients with renal failure? 1. The patient breathes rapidly to eliminate carbon dioxide. 2. The patient will retain bicarbonate in excess of normal. 3. The pH will decrease from the present value. 4. The patient's oxygen saturation level will improve. Answer: 1 Explanation: 1. In metabolic acidosis, compensation is accomplished through increased ventilation or "blowing off" CO2. This raises the pH by eliminating the volatile respiratory acid and compensates for the acidosis. 2. Because compensation must be performed by the system other than the affected system, the patient cannot retain bicarbonate; the manifestation of metabolic acidosis of renal failure is a lower-than-normal bicarbonate value. 3. Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. 4. Oxygenation disturbance is not part of the acid-base status of the patient with renal failure. Page Ref: 266 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acidbase balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

14 ..

15) The nurse is reviewing the health problems for a group of assigned patients. Which patient does the nurse recognize as being at increased risk for developing metabolic alkalosis? 1. Patient with bulimia 2. Patient on dialysis 3. Patient with venous stasis ulcer 4. Patient with COPD Answer: 1 Explanation: 1. Metabolic alkalosis may be caused by loss of acid or excess bicarbonate in the body. Vomiting is one way for the body to lose acid. 2. A patient receiving dialysis has kidney failure, which causes metabolic acidosis. 3. A venous stasis ulcer does not result in an acid‒base disorder. 4. The patient diagnosed with COPD typically has hypercapnea and respiratory acidosis. Page Ref: 274 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

15 ..

16) The nurse is caring for a patient who is anxious and dizzy following a traumatic experience. The arterial blood gas findings include pH 7.48, PaO2 110, PaCO2 25, and HCO3 24. Which intervention should the nurse expect to be prescribed to correct this problem? 1. Encourage the patient to breathe in and out slowly into a paper bag. 2. Immediately administer oxygen via a mask and monitor oxygen saturation. 3. Prepare to start an intravenous fluid bolus using isotonic fluids. 4. Anticipate the administration of intravenous sodium bicarbonate. Answer: 1 Explanation: 1. This patient is exhibiting signs of hyperventilation, which is confirmed with the blood gas results of respiratory alkalosis. Breathing into a paper bag will help the patient to retain carbon dioxide and lower oxygen levels to normal, correcting the cause of the problem. 2. The oxygen levels are high, so oxygen is not indicated and would exacerbate the problem if given. Intravenous fluids would not be the initial intervention. 3. Not enough information is given to determine the need for intravenous fluids. 4. Bicarbonate would be contraindicated as the pH is already high. Page Ref: 280 Cognitive Level: Evaluating Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

16 ..

17) A patient is prescribed 20 mEq of potassium chloride. For which reason is this patient most likely needing this electrolyte replacement? 1. Sustain respiratory function 2. Help regulate acid‒base balance 3. Keep a vein open 4. Encourage urine output Answer: 2 Explanation: 1. Potassium does not sustain respiratory function. 2. Potassium, the primary intracellular cation, plays a vital role in cell metabolism and cardiac and neuromuscular function. 3. Intravenous fluids are used to keep venous access, not potassium. 4. Urinary output is impacted by fluid intake not potassium. Page Ref: 248 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

17 ..

18) An elderly patient does not complain of thirst. What should the nurse do to assess this patient's hydration status? 1. Ask the physician for an order to begin intravenous fluid replacement. 2. Ask the physician to order a chest x-ray. 3. Monitor serum osmolality level. 4. Ask the physician for an order for a brain scan. Answer: 3 Explanation: 1. It is inappropriate to seek an IV at this stage. 2. There is no indication the patient is experiencing pulmonary complications; thus, a chest xray is not indicated. 3. The thirst mechanism declines with aging, which makes older adults more vulnerable to dehydration and hyperosmolality. The nurse should monitor the patient's serum osmolality level as a first step in determining hydration status before other detailed and invasive testing is done. 4. There is no data to support the need for a brain scan. Page Ref: 232 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.1 Describe the functions and regulatory mechanisms that maintain water and electrolyte balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

18 ..

19) An elderly patient who is being medicated for pain had an episode of incontinence. Which health problem is this patient at risk for developing? 1. Dehydration 2. Over-hydration 3. Fecal incontinence 4. A stroke Answer: 1 Explanation: 1. Functional changes of aging also affect fluid balance. Older adults who have self-care deficits, or who are confused, depressed, tube-fed, on bed rest, or taking medications (such as sedatives, tranquilizers, diuretics, and laxatives), are at greatest risk for fluid volume imbalance. 2. There is inadequate evidence to support the risk of over-hydration. 3. There is inadequate evidence to support the risk of fecal incontinence. 4. There is inadequate evidence to support the risk of a stroke. Page Ref: 234 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

19 ..

20) The nurse assesses a patient's weight loss as being 22 lbs. How many liters of fluid did this patient lose? Record your answer rounding to the nearest whole number. Answer: 10 Explanation: Each liter of body fluid weighs 1 kg or 2.2 lbs. This patient has lost 10 L of fluid. Page Ref: 235 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

20 ..

21) A postoperative patient with a fluid volume deficit is prescribed progressive ambulation, yet is weak from an inadequate fluid status. What should the nurse do to help this patient? 1. Assist the patient to maintain a standing position for several minutes. 2. Recommend that this patient be on bed rest. 3. Assist the patient to move into different positions in stages. 4. Contact physical therapy to provide a walker. Answer: 3 Explanation: 1. The patient should avoid prolonged standing. 2. Bed rest can promote skin breakdown. 3. The patient needs to be instructed how to avoid orthostatic hypotension, which involves assisting and teaching the patient how to move from one position to another in stages. 4. A physician referral is needed for physical therapy intervention and is not indicated in this situation. Page Ref: 239 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

21 ..

22) A postoperative patient is diagnosed with fluid volume overload. What should the nurse expect to assess in this patient? 1. Poor skin turgor 2. Decreased urine output 3. Distended neck veins 4. Concentrated hemoglobin and hematocrit levels Answer: 3 Explanation: 1. Poor skin turgor is associated with fluid volume deficit. 2. Decreased urine output is associated with fluid volume deficit. 3. Circulatory overload causes manifestations such as a full, bounding pulse; distended neck and peripheral veins; increased central venous pressure; cough; dyspnea; orthopnea; rales in the lungs; pulmonary edema; polyuria; ascites; peripheral edema, or if severe, anasarca, in which dilution of plasma by excess fluid causes a decreased hematocrit and blood urea nitrogen (BUN); and possible cerebral edema. 4. Increased hemoglobin and hematocrit values are associated with fluid volume deficit. Page Ref: 238 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

22 ..

23) An older patient is at home after being diagnosed with fluid volume overload. What should the nurse instruct this patient to do? 1. Wear support hose. 2. Keep legs in a dependent position. 3. Avoid wearing shoes while in the home. 4. Try to sleep without extra pillows. Answer: 1 Explanation: 1. The nurse should instruct the patient about ways to decrease dependent edema, which include wearing support stockings, elevating feet when in a sitting position, and resting in a recliner or bed with extra pillows. 2. The patient should elevate the legs. 3. As long as the shoes are well fitting, there is no reason to avoid wearing them. 4. It is appropriate for the patient to use extra pillows to keep the head up while sleeping. Page Ref: 244 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

23 ..

24) A patient is diagnosed with fluid retention related to kidney disease. Which electrolyte imbalance is this patient most likely experiencing? 1. Hypokalemia 2. Hypernatremia 3. Carbon dioxide 4. Magnesium Answer: 2 Explanation: 1. The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations in potassium levels. 2. The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. 3. Carbon dioxide abnormalities are not normally seen in this type of patient. 4. Magnesium abnormalities are not normally seen in this type of patient. Page Ref: 246 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

24 ..

25) An older patient experiences watery diarrhea for several days with abdominal and muscle cramping. Which imbalance is this patient most likely experiencing? 1. Hypernatremia 2. Hyponatremia 3. Fluid volume excess 4. Hyperkalemia Answer: 2 Explanation: 1. Hypernatremia is associated with fluid retention and overload. Fluid volume excess is associated with hypernatremia. 2. The older patient has watery diarrhea, which contributes to the loss of sodium. The abdominal and muscle cramps are manifestations of a low serum sodium level. 3. This patient is more likely to develop clinical manifestations associated with fluid volume deficit. 4. Hyperkalemia is associated with cardiac dysrhythmias. Page Ref: 245 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

25 ..

26) A patient is admitted with hypernatremia caused by being stranded on a boat in the Atlantic Ocean for five days without a fresh water source. What is this patient at risk for developing? 1. Pulmonary edema 2. Atrial dysrhythmias 3. Cerebral bleeding 4. Stress fractures Answer: 3 Explanation: 1. Pulmonary edema is not associated with dehydration. 2. Atrial dysrhythmias are not a factor for this patient. 3. The brain experiences the most serious effects of cellular dehydration. As brain cells contract, the brain shrinks, which puts mechanical traction on cerebral vessels. These vessels may tear, bleed, and lead to cerebral vascular bleeding. 4. There have been no activities to support the development or occurrence of stress fractures. Page Ref: 247 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.3 Describe the pathophysiology and manifestations of hyponatremia and hypernatremia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

26 ..

27) A patient is diagnosed with acute renal failure. Which electrolyte should the nurse expect to be most affected with this disorder? 1. Calcium 2. Magnesium 3. Phosphorous 4. Potassium Answer: 4 Explanation: 1. This patient will not be likely to develop a calcium imbalance. 2. This patient will not be likely to develop a magnesium imbalance. 3. This patient will not be likely to develop a phosphorous imbalance. 4. Because the kidneys are the principal organs involved in the elimination of potassium, renal failure can lead to potentially serious elevations of serum potassium levels. Page Ref: 252 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

27 ..

28) A patient who is taking digoxin (Lanoxin) is admitted with possible hypokalemia. What should the nurse realize might occur with this patient? 1. Digoxin toxicity may occur. 2. A higher dose of digoxin (Lanoxin) may be needed. 3. A diuretic may be needed. 4. Fluid volume deficit may occur. Answer: 1 Explanation: 1. Hypokalemia increases the risk of digitalis toxicity in patients who receive this drug for heart failure. 2. More digoxin is not needed. 3. A diuretic may cause further fluid loss. 4. There is inadequate information to assess for concerns related to fluid volume deficits. Page Ref: 251 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

28 ..

29) A patient is prescribed 40 mEq potassium as a replacement. How should the nurse plan to administer this medication? 1. Directly into the venous access line 2. Mixed in the prescribed intravenous fluid 3. Via a rectal suppository 4. Via intramuscular injection Answer: 2 Explanation: 1. Never administer undiluted potassium directly into a vein. 2. The intravenous route is the recommended route for diluted potassium. 3. The nurse should administer diluted potassium into the patient's intravenous line. 4. The nurse should administer diluted potassium into the patient's intravenous line. Page Ref: 251 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

29 ..

30) An older patient with a history of sodium retention experiences "heart skipping beats" and leg tremors. What should the nurse ask this patient regarding these symptoms? 1. "Have you stopped taking your digoxin medication?" 2. "When was the last time you had a bowel movement?" 3. "Were you doing any unusual physical activity?" 4. "Are you using a salt substitute?" Answer: 4 Explanation: 1. Although this patient may be prescribed digoxin, this is not the primary focus of this question. 2. The patient's bowel habits are not of concern at this time. 3. The cardiac and musculoskeletal discomforts being reported are not consistent with physical exertion. 4. The patient has a history of sodium retention and might think that a salt substitute can be used. Advise patients who are taking a potassium supplement or potassium-sparing diuretic to avoid salt substitutes, which usually contain potassium. Page Ref: 251 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

30 ..

31) A patient is recovering from a parathyroidectomy. What should the nurse include when teaching health promotion activities to this patient? 1. Drink one glass of red wine per day. 2. Avoid the sun. 3. Milk and milk-based products will ensure an adequate calcium intake. 4. Red meat is the protein source of choice. Answer: 3 Explanation: 1. This patient should avoid alcohol. 2. This patient can benefit from sun exposure. 3. This patient is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk and milk-based products. 4. Protein monitoring is not indicated. Page Ref: 257 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

31 ..

32) A patient is admitted for treatment of hypercalcemia. Which type of intravenous fluid should the nurse expect to be prescribed for this patient? 1. Dextrose 5% and water 2. Dextrose 5% and 0.9% normal saline 3. Dextrose 5% and 0.45% normal saline 4. Normal saline Answer: 4 Explanation: 1. If isotonic saline is not used, the patient is at risk for hyponatremia in addition to the hypercalcemia. 2. This solution is hypertonic. 3. This solution is hypertonic. 4. Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys. Page Ref: 260 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

32 ..

33) A patient is diagnosed with diabetic ketoacidosis. Which electrolyte should the nurse expect to be replaced in this patient? 1. Sodium 2. Potassium 3. Calcium 4. Magnesium Answer: 4 Explanation: 1. The patient will not typically have an increased need for sodium. 2. The patient will not typically have an increased need for potassium. 3. The patient will not typically have an increased need for calcium. 4. One risk factor for hypomagnesemia is an endocrine disorder, including diabetic ketoacidosis. Page Ref: 262 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.6 Describe the pathophysiology and manifestations of hypomagnesemia and hypermagnesemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

33 ..

34) An older patient with peripheral neuropathy has been taking magnesium supplements. Which symptoms indicate this patient may have hypermagnesemia? 1. Hypotension, warmth, and sweating 2. Nausea and vomiting 3. Hyperreflexia 4. Excessive urination Answer: 1 Explanation: 1. Elevations in magnesium levels are accompanied by hypotension, warmth, and sweating. 2. Lower levels of magnesium are associated with nausea and vomiting. 3. Lower levels of magnesium are associated and hyperreflexia. 4. Urinary changes are not noted. Page Ref: 263 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.6 Describe the pathophysiology and manifestations of hypomagnesemia and hypermagnesemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

34 ..

35) A patient is admitted with burns over 50% total body surface area. Which electrolyte imbalance is this patient at risk for developing? 1. Hypercalcemia 2. Hypophosphatemia 3. Hypernatremia 4. Hypermagnesemia Answer: 2 Explanation: 1. Patients who experience burns are not at an increased risk for developing increased blood calcium levels. 2. Causes of hypophosphatemia include stress responses and extensive burns. 3. Patients who experience burns are not at an increased risk for developing increased blood sodium levels. 4. Patients who experience burns are not at an increased risk for developing increased blood magnesium levels. Page Ref: 264 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

35 ..

36) A patient is diagnosed with hyperphosphatemia. Which additional electrolyte imbalance might this patient experience? 1. Calcium 2. Sodium 3. Potassium 4. Chloride Answer: 1 Explanation: 1. Excessive serum phosphate levels cause few specific symptoms. The effects of high serum phosphate levels on nerves and muscles are more likely the result of hypocalcemia that develops secondary to an elevated serum phosphorus level. The phosphate in the serum combines with ionized calcium, and the ionized serum calcium level falls. 2. There is no direct correlation between levels of phosphorus and that of sodium. 3. There is no direct correlation between levels of phosphorus and that of potassium. 4. There is no direct correlation between levels of phosphorus and that of chloride. Page Ref: 265 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

36 ..

37) The nurse is reviewing a patient's blood pH level. What system in the body does the nurse recognize as contributing to the regulation of blood pH? Select all that apply. 1. Renal 2. Cardiac 3. Buffers 4. Respiratory 5. Integumentary Answer: 1, 3, 4 Explanation: 1. Three systems work together in the body to maintain the pH despite continuous acid production, and the renal system is one of them. 2. The cardiac system is responsible for circulating blood to the body. It does not help maintain the body's pH. 3. Three systems work together in the body to maintain the pH despite continuous acid production, and the buffer system is one of them. 4. Three systems work together in the body to maintain the pH despite continuous acid production, and the respiratory system is one of them. 5. The integumentary system does not participate in the regulation of body pH. Page Ref: 266 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acidbase balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

37 ..

38) A patient's respiration rate is 30 per minute and very deep. What disorder should the nurse suspect is occurring in this patient? 1. Hypernatremia 2. Increased carbon dioxide in the blood 3. Hypertension 4. Pain Answer: 2 Explanation: 1. Hypernatremia is associated with profuse sweating and diarrhea. 2. Acute increases in either carbon dioxide or hydrogen ions in the blood stimulate the respiratory center in the brain. As a result, both the rate and depth of respiration increase. The increased rate and depth of lung ventilation eliminates carbon dioxide from the body, and carbonic acid levels fall, which brings the pH to a more normal range. 3. The respiratory rate in a patient exhibiting hypertension is not altered. 4. Pain may be manifested in rapid, shallow respirations. Page Ref: 266 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.8 Describe the functions and regulatory mechanisms that maintain acidbase balance in the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

38 ..

39) The blood gases of a patient with an acid‒base disorder show a blood pH outside of normal limits. What should the nurse consider is occurring with this patient? 1. Fully compensated 2. Demonstrating anaerobic metabolism 3. Partially compensated 4. In need of intravenous fluids Answer: 3 Explanation: 1. If the pH is restored to within normal limits, the disorder is said to be fully compensated. 2. Anaerobic metabolism results when the body's cells become hypoxic. 3. If the pH is restored to within normal limits, the disorder is said to be fully compensated. When these changes are reflected in arterial blood gas (ABG) values but the pH remains outside normal limits, the disorder is said to be partially compensated. 4. Although the patient may be in need of intravenous fluids, this is not the most correct or definitive answer. Page Ref: 271 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

39 ..

40) A patient's blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. Which acidbase disorder is this patient demonstrating? 1. Respiratory acidosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis Answer: 4 Explanation: 1. Respiratory acidosis and metabolic acidosis are both consistent with pH less than 7.35. 2. Respiratory acidosis and metabolic acidosis are both consistent with pH less than 7.35. 3. Respiratory alkalosis is associated with a pH greater than 7.45 and a PaCO2 of less than 35 mmHg. It is caused by respiratory-related conditions. 4. Arterial blood gases (ABGs) show a pH greater than 7.45 and bicarbonate level greater than 26 mEq/L when the patient is in metabolic alkalosis. Page Ref: 274 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

40 ..

41) An older postoperative patient using patient-controlled anesthesia (PCA) is demonstrating lethargy, confusion, and a respiratory rate of 8 per minute. Which acid‒base disorder might this patient be experiencing? 1. Respiratory acidosis 2. Metabolic acidosis 3. Respiratory alkalosis 4. Metabolic alkalosis Answer: 1 Explanation: 1. Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. 2. The patient condition being described is respiratory, not metabolic, in nature. 3. Respiratory alkalosis is characterized by anxiety with hyperventilation. 4. The patient condition being described is respiratory, not metabolic, in nature. Page Ref: 276 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance.

41 ..

42) A patient is prescribed a 1200 mL daily fluid restriction. The patient's IV is infusing at a keep open rate of 10 mL/hr. The patient has no additional IV medications. How much fluid should the patient be permitted from 0700 until 1500? Record your answer rounding to the nearest whole number. Answer: 480 mL Explanation: Fluid allowed is calculated by figuring the total daily IV intake (in this case, 10 mL/hr × 24 hours = 240 mL/day), subtracting that total from the daily allowance (in this case, 1200 mL − 240 mL = 960 mL). The amount calculated is then distributed as 50% for the traditional day shift, 25%‒33% for the traditional evening shift, and the remainder for the traditional night shift. In this case, 50% of 960 is 480 mL. Page Ref: 241 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

42 ..

43) A patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Select all that apply. 1. Administer the dose IV push over 3 minutes. 2. Monitor the injection site for redness. 3. Add the ordered dose to the IV hanging. 4. Use an infusion pump for the IV. 5. Monitor fluid intake and output. Answer: 2, 4, 5 Explanation: 1. KCL should be given via IV infusion, not IV push. 2. The nurse should monitor the injection site for redness. 3. KCL should not be added to the IV hanging. 4. The nurse should use an infusion pump for the IV infusion. 5. The nurse should monitor patient fluid intake and output. Page Ref: 250 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

43 ..

44) The nurse is reviewing care needs for a group of assigned patients. Which patient should the nurse identify as being at risk for the development of hypercalcemia? Select all that apply. 1. The patient with a malignancy 2. The patient taking lithium 3. The patient who uses excessive sunscreen 4. The patient with hyperparathyroidism 5. The patient who overuses antacids Answer: 1, 2, 4, 5 Explanation: 1. Patients with malignancy are at risk for development of hypercalcemia due to destruction of bone or the production of hormone-like substances by the malignancy. 2. Lithium can result in hypercalcemia. 3. The patient who uses sunscreen to excess is more likely to have a vitamin D deficiency, which would result in hypocalcemia. 4. Hypercalcemia can result from hyperparathyroidism, which causes release of calcium from the bones, increased calcium absorption in the intestines, and retention of calcium by the kidneys. 5. Overuse of antacids can result in hypercalcemia. Page Ref: 259 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

44 ..

45) The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which food should the nurse suggest for this patient? Select all that apply. 1. Romaine lettuce 2. Seafood 3. White rice 4. Bananas 5. Chocolate Answer: 1, 2, 4, 5 Explanation: 1. Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Magnesium is plentiful in green vegetables such as romaine. 2. Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Magnesium is plentiful in seafood. 3. Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. White rice is not high in magnesium. 4. Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Magnesium is plentiful in bananas. 5. Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Magnesium is plentiful in chocolate. Page Ref: 262 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 10.6 Describe the pathophysiology and manifestations of hypomagnesemia and hypermagnesemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

45 ..

46) A patient has a serum phosphate level of 4.7 mg/dL. Which treatment should the nurse expect to be prescribed for this patient? Select all that apply. 1. IV normal saline 2. Calcium-containing antacids 3. IV potassium phosphate 4. Additional milk intake 5. Increased vitamin D intake Answer: 1, 2 Explanation: 1. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate. 2. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Calcium-containing antacids bind the phosphate for excretion through the GI tract. 3. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV potassium phosphate is a treatment for low phosphate 4. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Milk is a high phosphate food and should be discouraged. 5. Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Excess vitamin D increases phosphate absorption and can lead to hyperphosphatemia. Page Ref: 265 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.7 Describe the pathophysiology and manifestations of hypophosphatemia and hyperphosphatemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

46 ..

47) A patient newly diagnosed with diabetes mellitus has nausea, vomiting, and abdominal pain. ABG results include a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment finding should the nurse anticipate in this patient? Select all that apply. 1. Tachycardia 2. Weakness 3. Dysrhythmias 4. Kussmaul respirations 5. Cold, clammy skin Answer: 2, 3, 4 Explanation: 1. These ABG results, coupled with the patient's recent diagnosis of diabetes mellitus and history of vomiting would lead the nurse to suspect metabolic acidosis. Tachycardia is not associated with metabolic acidosis, which this patient is experiencing. 2. These ABG results, coupled with the patient's recent diagnosis of diabetes mellitus and history of vomiting would lead the nurse to suspect metabolic acidosis. Weakness is a symptom of metabolic acidosis. 3. These ABG results, coupled with the patient's recent diagnosis of diabetes mellitus and history of vomiting would lead the nurse to suspect metabolic acidosis. Dysrhythmias are symptoms of metabolic acidosis. 4. These ABG results, coupled with the patient's recent diagnosis of diabetes mellitus and history of vomiting would lead the nurse to suspect metabolic acidosis. Kussmaul respirations are symptoms of metabolic acidosis. 5. These ABG results, coupled with the patient's recent diagnosis of diabetes mellitus and history of vomiting would lead the nurse to suspect metabolic acidosis. Warm, flushed skin is a symptom of metabolic acidosis. Page Ref: 272 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

47 ..

48) A patient has a serum sodium level of 145 mEq/L, serum chloride level of 114 mEq/L, and serum bicarbonate level of 20 mEq/L. What should the nurse calculate as being this patient's anion gap? Record your answer rounding to the nearest whole number. Answer: 11 mEq/L Explanation: The anion gap is calculated by subtracting the sum of two measured anions, chloride and bicarbonate, from the concentration of the major cation, sodium. For this patient the equation would be 145 − (114 + 20) = 145 − 134 = 11 mEq/L. Page Ref: 271 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.9 Describe the pathophysiology and manifestations of metabolic acidosis, metabolic alkalosis, respiratory acidosis, and respiratory alkalosis, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered fluid, electrolyte, and acid-base balance. 49) A patient weighing 176 lbs. is recovering from mild dehydration. The patient is awake, alert, and can safely take oral fluids. How many mL of fluid should the nurse instruct the patient to consume every day? Record your answer rounding to the nearest whole number. Answer: 2400 mL Explanation: Adults require approximately 30 mL per kilogram of body weight per day for body maintenance. First convert the patient's weight in lbs. to kg by dividing 176/2.2 = 80 kg. Next multiply the amount of fluid per kg by the body weight in kg, or 30 mL/kg × 80 kg = 2400 mL. The nurse should instruct the patient to ingest 2400 mL of fluid per day. Page Ref: 237 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance. 48 ..

49 ..

50) A patient with fluid overload is prescribed furosemide (Lasix) 20 mg by mouth each day. What should the nurse include when teaching the patient about this medication? Select all that apply. 1. Expect urination to increase. 2. Expect to feel weak and dizzy. 3. Measure body weight every day. 4. Report swelling of the face or hands. 5. Take the medication before going to sleep. Answer: 1, 3, 4 Explanation: 1. Teaching for the patient prescribed a diuretic should include expecting the medication to increase urination. 2. Weakness and dizziness are not expected and should be reported to the healthcare provider. 3. Teaching for the patient prescribed a diuretic should include measuring body weight every day. 4. Teaching for the patient prescribed a diuretic should include reporting swelling of the face or hands to the healthcare provider. 5. The medication should be taken in the morning or afternoon so that sleep is not interrupted to urinate. Page Ref: 241 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 10.2 Describe the pathophysiology and manifestations of fluid volume deficit and fluid volume excess, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered fluid, electrolyte, and acid-base balance.

50 ..

51) A patient with chronic renal failure has an occluded arteriovenous fistula, and routine hemodialysis is delayed. However, the patient's serum potassium level is 6.0 mEq/L. What should the nurse expect to be prescribed for this patient? Select all that apply. 1. Insulin 2. Dextrose 10% 3. Furosemide (Lasix) 4. Sodium bicarbonate 5. Sodium polystyrene sulfonate (Kayexalate) Answer: 1, 2, 4 Explanation: 1. Insulin is used in the emergency treatment of moderate to severe hyperkalemia (serum potassium > 6.0 to 6.5 mEq/L). Insulin promotes the movement of potassium into the cell. 2. Hypertonic dextrose (10% to 50%) is used in the emergency treatment of moderate to severe hyperkalemia (serum potassium > 6.0 to 6.5 mEq/L). Glucose prevents hypoglycemia. 3. Furosemide (Lasix) is a potassium-wasting diuretic used to enhance renal excretion of potassium. The patient is in chronic renal failure and most likely does not have a urine output. 4. Sodium bicarbonate may be used in the emergency treatment of moderate to severe hyperkalemia (serum potassium > 6.0 to 6.5 mEq/L). Sodium bicarbonate elevates the serum pH; potassium is moved into the cell in exchange for hydrogen ion. 5. Sodium polystyrene sulfonate (Kayexalate) is used to treat moderate or severe hyperkalemia. Page Ref: 253 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10.4 Describe the pathophysiology and manifestations of hypokalemia and hyperkalemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered fluid, electrolyte, and acid-base balance.

51 ..

52) The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What finding did the nurse use to come to this conclusion? Select all that apply. 1. Heart rate 88 and regular 2. Complaints of fingers tingling 3. Contraction of the facial muscle 4. Asked when the foot numbness would go away 5. Carpal spasm with blood pressure measurement Answer: 2, 3, 4, 5 Explanation: 1. Hypocalcemia causes bradycardia. A regular heart rate of 88 is within normal limits. 2. Manifestations of hypocalcemia include numbness and tingling in the hands. 3. Muscle spasms of the face occur such as Chvostek sign, which is the contraction of the facial muscles. 4. Manifestations of hypocalcemia include numbness and tingling in the hands and feet. 5. Trousseau sign, a carpal spasm induced by inflating a blood pressure cuff, occurs with hypocalcemia. Page Ref: 257 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10.5 Describe the pathophysiology and manifestations of hypocalcemia and hypercalcemia, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered fluid, electrolyte, and acid-base balance.

52 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 11 Nursing Care of Patients Experiencing Trauma and Shock 1) A patient is brought to the emergency department with injuries sustained in a motor vehicle crash. What should the nurse consider as the cause of this patient's injuries? 1. Trauma 2. Not wearing a seat restraint 3. A drunk driver 4. Not paying attention while driving Answer: 1 Explanation: 1. Trauma is defined as injury to human tissues and organs resulting from the transfer of energy from the environment. Trauma encompasses a variety of injuries, including those from motor vehicle crashes. 2. There is insufficient information to determine whether the patient was wearing a seat restraint. 3. There is insufficient information to determine whether the accident was caused by a drunk driver. 4. There is insufficient information to determine whether the patient was paying attention while driving. Page Ref: 285 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

1 ..

2) A patient recovering from a traumatic gunshot wound asks when discharge will occur. Which response should the nurse make? 1. "Right now there is no way of knowing how long you will be hospitalized." 2. "I would say in a few weeks." 3. "Probably never." 4. "As soon as the wound heals, you can return to work." Answer: 1 Explanation: 1. Nurses provide a vital link in both the physical and psychosocial care to the injured patient and family. In caring for the patient who has experienced trauma, nurses must consider not only the initial physical injury, but also its long-term consequences, including rehabilitation. Trauma may alter the patient's previous way of life, potentially affecting independence, mobility, cognitive thinking, and appearance. The nurse should respond that there is no way of knowing how soon the patient can return home. 2. The nurse should not put a time limit of a few weeks on the patient's recovery from trauma. 3. There is no way of knowing if the patient will be unable to return home. 4. The nurse has no way of knowing the extent of the damage caused by the gunshot wound and cannot predict when the patient can return to work. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Stress Management Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

2 ..

3) An older patient is admitted after falling on the steps at home. Which component of trauma should the nurse consider when planning care for the patient? Select all that apply. 1. Host 2. Environment 3. Intention 4. Source 5. Transmission Answer: 1, 2, 3 Explanation: 1. The host is the person or group at risk of injury. Multiple factors influence the host's potential for injury: age, sex, race, economic status, preexisting illnesses, and use of substances such as street drugs and alcohol. 2. The environment in which the trauma occurred needs to be taken into consideration. 3. The event was either intentional or unintentional. As the patient fell on the steps at home, the event was most likely unintentional. 4. Source is not a component of a traumatic event. 5. Transmission is not a component of a traumatic event. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

3 ..

4) A patient comes into the emergency department with leg pain after falling on ice. For which classification of injuries should the nurse expect to plan care for this patient? 1. Class 3 minor 2. Class 1 minor 3. Class 1 penetrating 4. Class 3 penetrating Answer: 1 Explanation: 1. Trauma patients are classified as Class 1, 2, or 3 based on factors including mechanism of injury, vehicle speed, height of falls, and location of penetrating injuries. Class 3 trauma is the least severe. An example would be a same-level fall without loss of consciousness or significant injury. 2. Class 1 trauma involves life-threatening injuries likely to require medical specialists or immediate surgical intervention. Minor trauma causes injury to a single part or system of the body and is usually treated in a physician's office or in the hospital emergency department. A single bone fracture, small second-degree burns, or a laceration requiring sutures are examples of minor trauma. 3. Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures. 4. Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures. Page Ref: 287 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

4 ..

5) A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. Which mechanism of injury most likely caused this patient's injuries? 1. Crushing 2. Shearing 3. Deceleration 4. Blast Answer: 1 Explanation: 1. A crushing injury occurs from a high force that leads to tissue destruction. The collapsing wall most likely caused crushing injuries. 2. Shearing occurs when structures slip across each other. 3. Deceleration is the decrease in speed of a moving object. 4. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Page Ref: 287 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

5 ..

6) A patient was admitted with a head injury caused by rapid acceleration and deceleration. How should the nurse expect this patient's injuries to be classified? 1. Blunt 2. Shearing 3. Blast 4. Minor Answer: 1 Explanation: 1. Blunt trauma occurs when there is no communication between the damaged tissues and the outside environment. It is caused by various forces including deceleration, acceleration, shearing, compression, and crushing. 2. Shearing occurs when structures slip across each other. 3. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. 4. Minor trauma causes injury to a single part or system of the body and is usually treated in a physician's office or in the hospital emergency department. Page Ref: 287 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

6 ..

7) A patient experiences a thermal injury. Which mechanism should the nurse consider as the most likely cause of this patient's injuries? 1. Fire 2. Lightning 3. Ultraviolet radiation 4. Gunshot Answer: 1 Explanation: 1. The energy source for the patient's injury is thermal. Mechanisms of injury for thermal injuries include fire, heating appliances, and freezing temperatures. 2. The energy source for lightning is electrical. 3. The energy source for ultraviolet radiation is physical. 4. The energy source for a gunshot is mechanical. Page Ref: 286 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

7 ..

8) A pediatric patient is admitted after ingesting a household cleaning solution. For which energy source should care be planned for this patient? 1. Chemical 2. Physical 3. Thermal 4. Mechanical Answer: 1 Explanation: 1. The energy source for drugs, poisons, and industrial chemicals is chemical. 2. The energy source for physical assault, drowning, or explosions is physical. 3. The energy source for heating appliances, fire, or freezing temperatures is thermal. 4. The energy source for motor vehicle accidents is mechanical. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

8 ..

9) A patient recovering from a motor vehicle accident asks how so many injuries occurred when the other car "barely" made contact. How should the nurse respond? 1. "The car that hit you transferred a large amount of energy to your body, causing these injuries." 2. "You have other health problems that make the injuries worse." 3. "The driver of the other car intended to hit you." 4. "Because you are older, your injuries will be worse." Answer: 1 Explanation: 1. The nurse should explain the transfer of energy to the patient's body that caused the injuries. 2. Referring to other health problems identifies characteristics of the host but does not explain the number or types of injuries. 3. This response addresses the intention of the trauma but does not explain the number or types of injuries. 4. Referring to the patient's age identifies characteristics of the host but does not explain the number or types of injuries. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

9 ..

10) A construction worker was admitted after falling from the roof of a building. Which energy source should the nurse use to plan this patient's care? 1. Gravitational 2. Mechanical 3. Physical 4. Electrical Answer: 1 Explanation: 1. The energy source for a fall is gravitational. 2. The energy source for motor vehicle accidents is mechanical. 3. The energy source for physical assaults, explosions, and drowning is physical. 4. The energy source for lightning is electrical. Page Ref: 286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

10 ..

11) A patient with injuries from a motor vehicle crash develops hypotension and severe jugular distension with a tracheal deviation. What should the nurse suspect is occurring in this patient? 1. Tension pneumothorax 2. Hemorrhage 3. Compensatory shock 4. Hypovolemic shock Answer: 1 Explanation: 1. A tension pneumothorax is life-threatening and requires immediate intervention. On inspiration, air enters the pleural space, does not escape on expiration, and increases the intrapleural pressure. This pressure collapses the injured lung and shifts the mediastinal contents, compressing the heart, great vessels, trachea, and eventually the uninjured lung. 2. The patient would not have jugular vein distention with a hemorrhage. 3. The patient would not have jugular vein distention with compensatory shock. 4. The patient would not have jugular vein distention with hypovolemic shock. Page Ref: 289 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

11 ..

12) A patient experiences blunt trauma to the abdomen after a motor vehicle crash. What should be assessed first? 1. Airway for patency 2. Abdomen for any abnormalities 3. Cervical spine for tenderness 4. Signs of neurological deficits Answer: 1 Explanation: 1. Assessment of the airway is the highest priority in the trauma patient. Assessment includes determining airway patency. If the patient is unresponsive, manual opening of the airway using a jaw thrust or chin lift maneuver is necessary. Once the airway is opened, any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema is identified. If the patient is responsive and can vocalize, that is a good indication that the airway is clear. 2. Another assessment must take place initially. 3. Another assessment must take place initially. 4. The neurological assessment is always a concern; however, this patient has a blunt trauma injury from a motor vehicle crash. Therefore, this would not be the initial assessment. Page Ref: 293 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

12 ..

13) A patient with a penetrating wound to the neck has dyspnea, cyanosis, and evidence of subcutaneous emphysema. What should the nurse expect to be completed first for this patient? 1. Intubate because of the severe wound. 2. Notify the next of kin. 3. Prepare for x-rays of the lumbar area to assess for fractures. 4. Administer a beta blocker to alleviate the sympathetic response. Answer: 1 Explanation: 1. Penetrating trauma to the neck is associated with a high degree of morbidity and mortality. Airway involvement includes dyspnea, cyanosis, subcutaneous emphysema, hoarseness, or air bubbling from the wound. The key is early identification of the need for intubation before the patient has no airway at all. 2. Another action is more critical initially. 3. Another action is more critical initially. 4. Another action is more critical initially. Page Ref: 288 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

13 ..

14) The nurse suspects that a patient who was in a motor vehicle crash does not have a cervical spine injury. What did the nurse assess to come to this conclusion? 1. Alert without midline cervical tenderness 2. Lacking motor response in lower extremities 3. Lacking deep tendon reflexes 4. Lethargic and confused Answer: 1 Explanation: 1. There is a decreased probability of a cervical spine injury if the following criteria are met: absence of midline cervical spine tenderness; normal alertness; absence of intoxication; absence of a painful distracting injury; and no focal neurological deficits. 2. A lack of motor response would be an indication of a cervical spine injury. 3. A lack of deep tendon reflexes would be an indication of a cervical spine injury. 4. Lethargy and confusion would be indications of a cervical spine injury. Page Ref: 288 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

14 ..

15) A patient with physical injuries sustained in a gang fight has a blood pressure of 80/50 mmHg, with a pulse of 120 and thready. Which diagnostic test should the nurse expect to be performed to provide the fastest information? 1. Sonogram 2. Complete blood count 3. Urinalysis 4. Serum electrolyte levels Answer: 1 Explanation: 1. The focused assessment by sonography in trauma, or FAST, identifies blood in body cavities where it is not supposed to be. The primary focus is on the peritoneum. Because the patient was in a fight and has a low blood pressure and thready pulse, this diagnostic test would provide the fastest information. 2. A complete blood count would not provide the fastest information for this patient. 3. A urinalysis would not provide the fastest information for this patient. 4. Serum electrolyte levels would not provide the fastest information for this patient. Page Ref: 295 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

15 ..

16) A patient is admitted with possible head and spinal cord injuries sustained after falling from a ladder. Which diagnostic test should the nurse expect to be prescribed that will identify the type and extent of this patient's injuries? 1. Magnetic resonance imaging 2. Cervical spine x-rays 3. Spinal cord x-rays 4. Cerebral angiogram Answer: 1 Explanation: 1. Magnetic resonance imaging scans reveal injuries to the brain and spinal cord. 2. Cervical spine x-rays can detect fractures of the vertebrae but not injuries to the brain. 3. Spinal cord x-rays can detect fractures of the vertebrae but not injuries to the brain. 4. A cerebral angiogram can detect injuries to the brain but not to the spinal cord. Page Ref: 295 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

16 ..

17) A victim of a multivehicle automobile crash has slurred speech and is lethargic. Which diagnostic test should be anticipated for this patient? Select all that apply. 1. Blood alcohol level 2. Urine drug screen 3. Skull x-rays 4. Chest x-ray 5. Urinalysis Answer: 1, 2 Explanation: 1. Because alcohol alters a person's level of consciousness, a blood alcohol level would likely be prescribed for a patient with slurred speech and lethargy. 2. Some drugs can cause lethargy and slurred speech. A urine drug screen would likely be prescribed for this patient. 3. This diagnostic test may or may not be indicated for the patient. 4. A chest x-ray would likely be prescribed, but not because of the slurred speech or lethargy. 5. Urinalysis will most likely be done, however not because of slurred speech or lethargy. Page Ref: 295 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

17 ..

18) A trauma patient is experiencing ongoing progression of shock. What finding caused the nurse to come to this conclusion? 1. Decrease in serum glucose level 2. Drop in blood urea nitrogen level 3. Increased eosinophil level 4. Low serum cardiac enzyme level Answer: 1 Explanation: 1. As shock progresses, liver functions are impaired, and hypoglycemia develops. 2. A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow. 3. An increase in eosinophils indicates an allergic response. 4. Low serum cardiac enzymes indicate there is no myocardial damage. Page Ref: 306 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

18 ..

19) A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. Because there is not enough time for type and crossmatch, which type of blood will the patient likely receive? 1. O 2. A 3. B 4. AB Answer: 1 Explanation: 1. Type O blood is the universal donor. ABO antibodies develop in the serum of people whose RBCs lack the corresponding antigen; these antibodies are called anti-A and antiB. 2. The person with blood type A has B antibodies. 3. The person with blood type B has A antibodies. 4. The person with AB has no antibodies (called a universal recipient). Page Ref: 295 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

19 ..

20) A patient with multiple gunshot wounds has received 8 units of blood; however, the blood bank has run out of blood for the patient. For which blood type can the patient receive any type of blood? 1. AB 2. A 3. B 4. O Answer: 1 Explanation: 1. The person with type AB blood has no antibodies, can receive any type of blood in an emergency, and is referred to as a universal recipient. 2. The person with blood type A has B antibodies. 3. The person with type B has A antibodies. 4. A person with the O blood type has both A and B antibodies and is considered a universal donor in an emergency situation. Page Ref: 295 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

20 ..

21) A patient admitted with multiple injuries is prescribed an intravenous colloid solution. Which solution would be appropriate for the nurse to infuse? 1. 25% albumin 2. 0.9% normal saline 3. Dextrose 5% and 0.45% normal saline 4. Dextrose 5% and water Answer: 1 Explanation: 1. Colloid solutions contain substances that should not diffuse through capillary walls. Colloids tend to remain in the vascular system and increase the osmotic pressure of the serum, causing fluid to move into the vascular compartment from the interstitial space. As a result, plasma volume expands. Colloid solutions used to treat shock include 5% albumin, 25% albumin, hetastarch, plasma protein fraction, and dextran. 2. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. 3. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. 4. Crystalloid solutions contain dextrose or electrolytes such as normal saline dissolved in water; they are either isotonic or hypotonic. All crystalloid solutions increase fluid volume in the intravascular and interstitial space. Page Ref: 313 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

21 ..

22) A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution should the nurse recognize would be best for this patient? 1. Ringer's lactate 2. Dextrose 5% and water 3. Dextrose 5% and 0.45% normal saline 4. Dextrose 5% and 0.9% normal saline Answer: 1 Explanation: 1. Ringer's lactate and 0.9% saline are the fluids of choice in treating hypovolemic shock, especially in the emergency phase of care while blood is being typed and crossmatched. Large amounts of these solutions may be infused rapidly, increasing blood volume and tissue perfusion. 2. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. However, approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. 3. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. However, approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. 4. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. However, approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Page Ref: 313 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

22 ..

23) A patient diagnosed with shock is prescribed dobutamine (Dobutrex). Which finding indicates this medication has been effective? 1. Increased heart rate

2. Reduced heart rate 3. Decreased respiratory rate 4. Decreased blood pressure Answer: 1 Explanation: 1. Dobutamine (Dobutrex) is a medication that mimics the fight-or-flight response of the sympathetic nervous system. The physiologic effect is improved perfusion and oxygenation of the heart, with increased stroke volume and heart rate, and increased cardiac output. Increased cardiac output, in turn, increases tissue perfusion and oxygenation. 2. This medication will not reduce the heart rate. 3. This medication will not reduce the respiratory rate. 4. This medication will not reduce the blood pressure. Page Ref: 312 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

23 ..

24) The nurse is preparing to administer intravenous nitroglycerin to a patient diagnosed with cardiogenic shock. What should the nurse do when administering this medication? 1. Use an infusion pump. 2. Administer with PVC tubing. 3. Use within 8 hours of reconstitution. 4. Allow the patient to get out of bed only with assistance. Answer: 1 Explanation: 1. Intravenous nitroglycerin must be mixed in glass bottles and infused through special, non-PVC tubing, because up to 40%-80% of nitroglycerin can be absorbed by PVC bags or tubing. 2. Intravenous nitroglycerin should not be administered with PVC tubing, because up to 40%80% of nitroglycerin can be absorbed by PVC bags or tubing. 3. This medication must be used within 4 hours of reconstitution. 4. The patient receiving intravenous nitroglycerin should be on bed rest, not assisted out of bed. Page Ref: 312 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

24 ..

25) A patient with a traumatic brain injury is being evaluated for brain death. Which finding should the nurse expect in this patient? Select all that apply. 1. Absence of gag or corneal reflex 2. Absence of oculovestibular reflex 3. Apnea with PaCO2 of 66 mmHg 4. Toxic metabolic disorders 5. Response to deep stimuli Answer: 1, 2, 3 Explanation: 1. An absence of the gag or corneal reflex is a clinical sign that is consistent with brain death. 2. An absence of the oculovestibular reflex is a clinical sign that is consistent with brain death. 3. Apnea with PaCO2 of 66 mmHg is a clinical sign that is consistent with brain death. 4. Toxic metabolic disorders are not consistent with brain death. 5. Responding to deep stimuli is not a sign consistent with brain death. Page Ref: 301 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

25 ..

26) The spouse of a patient with a severe head injury believes the patient is going to recover because of making movements without stimulation. What should the nurse explain to the spouse? 1. "With head injuries, the patient can continue to make movements, but these are reflexes that do not reflect brain function." 2. "Your spouse will likely recover in time." 3. "As long as oxygen gets to the brain, the patient will recover." 4. "Those movements indicate that the brain is dead." Answer: 1 Explanation: 1. One criterion of brain death is the lack of spontaneous movement; however, some spinal cord reflexes may be present. 2. The nurse should not tell the spouse that the patient will recover in time. 3. The nurse should not tell the spouse that the patient will recover as long as oxygen gets to the brain. 4. The patient has a brain injury; the movements are likely spinal cord reflexes rather than spontaneous movements. Additional testing must be done before brain death is diagnosed. Page Ref: 301 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

26 ..

27) A patient is brought to the emergency department with gunshot wounds to the abdomen and lower extremities. To protect the chain of evidence for these injuries, what should the nurse do? 1. Remove the patient's clothing and place in a breathable bag. 2. Cover the patient's hands with plastic bags. 3. Cut off the patient's clothing and bathe the skin and wounds as soon as possible. 4. Place clothing and other patient items on a bedside table and have a nursing assistant remove them when possible. Answer: 1 Explanation: 1. Each item of clothing removed from the patient must be placed in a breathable container, such as a paper bag, and documented appropriately. 2. The patient's hands should be covered with paper bags only if the patient died. 3. The clothing should not be cut off in order to bathe the patient's skin and wounds. 4. The patient's clothing and personal items should not be left on a bedside table for someone else to remove. This would not protect the chain of evidence. Page Ref: 298 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: V.6. Explore the impact of sociocultural, economic, legal and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

27 ..

28) An adult patient who has died from traumatic injuries is an organ donor. What should the nurse do when caring for this patient? 1. Maintain systolic blood pressure of 90 mmHg. 2. Keep oxygen saturation level at 75%. 3. Administer intravenous fluids to maintain a urine output of 25 mL per hour. 4. Perform external cardiac compressions to achieve a heart rate of 60 beats per minute. Answer: 1 Explanation: 1. When caring for an adult patient who is an organ donor, the nurse should maintain systolic blood pressure of 90 mmHg to keep the patient's organs perfused until removal. 2. The oxygen saturation level needs to be kept at 90% or greater. 3. Medications and fluids are provided to keep urine output at more than 30 mL per hour. 4. External cardiac compressions should not be performed. Page Ref: 302 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: V.6. Explore the impact of sociocultural, economic, legal and political factors influencing healthcare delivery and practice | NLN Competencies: Context and Environment; Ethical Comportment; Act in accordance with legal and regulatory requirements, including HIPAA, for faculty, students, patients, and families. | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

28 ..

29) A patient with traumatic injuries has lost approximately 300 mL of blood. What should the nurse expect to assess in this patient? 1. Slight increase in heart rate 2. Nonpalpable peripheral pulses 3. Narrowing pulse pressure 4. Increase in blood glucose level Answer: 1 Explanation: 1. With a slight decrease in circulating blood volume, usually less than 500 mL, the symptoms of shock are almost imperceptible. The pulse rate may be slightly elevated. If the injury is minor or of short duration, arterial pressure is usually maintained and no further symptoms occur. 2. Nonpalpable peripheral pulses are a sign of progressive shock. The patient is not in progressive shock. 3. Narrowing pulse pressure is a sign of progressive shock. The patient is not in progressive shock. 4. An increase in blood glucose level is a sign of progressive shock. The patient is not in progressive shock. Page Ref: 303, 306 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

29 ..

30) The nurse wants to calculate a patient's mean arterial pressure. Which vital sign measurement should the nurse use to make this calculation? 1. Blood pressure 2. Temperature 3. Respirations 4. Heart rate Answer: 1 Explanation: 1. The patient's blood pressure is needed to make this calculation. The mean arterial pressure can be calculated by multiplying the diastolic blood pressure by 2, adding the systolic pressure, and dividing this total by 3. 2. Temperature is not used to calculate mean arterial pressure. 3. Respiratory rate is not used to calculate mean arterial pressure. 4. Heart rate is not used to calculate mean arterial pressure. Page Ref: 303 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

30 ..

31) The nurse is providing medications to increase a patient's systemic vascular resistance. At which point will the nurse know that the patient has adequate tissue perfusion? 1. Mean arterial pressure reaches 60 mmHg. 2. Mean arterial pressure reaches 90 mmHg. 3. Blood pressure reaches 120/80 mmHg. 4. Urine output is 10 mL per hour. Answer: 1 Explanation: 1. A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys. 2. A mean arterial pressure of 90 mmHg is considered within normal limits. 3. A blood pressure of 120/80 mmHg is considered normal. 4. A urine output of 10 mL per hour would not indicate adequate renal perfusion. Page Ref: 303 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

31 ..

32) A patient has an estimated blood loss of 2 L and a mean arterial pressure ranging between 30 and 40 mmHg. If this patient's hemodynamic status is not corrected, what should the nurse realize can occur? 1. Failure of sodium-potassium pump 2. Cells shrinking 3. Full and bounding peripheral pulses 4. Metabolic alkalosis Answer: 1 Explanation: 1. With a blood loss of 2 L and a mean arterial pressure below 60 mmHg, the body cells switch from aerobic to anaerobic metabolism. The lactic acid formed as a by-product of anaerobic metabolism contributes to an acidotic state at the cellular level. Adenosine triphosphate, the source of cellular energy, is produced inefficiently. Lacking energy, the sodium-potassium pump fails. Potassium moves out of the cells while sodium and water move inward. 2. As this process continues, the cells swell, not shrink. 3. Peripheral pulses may not be palpable. 4. The body develops acidosis, not alkalosis. Page Ref: 304 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

32 ..

33) A patient who sustained a traumatic injury several days ago is hypotensive, oliguric, and has cool, pale skin and acidosis. For which type of shock should the nurse plan care for this patient? 1. Hypovolemic 2. Cardiogenic 3. Septic 4. Anaphylactic Answer: 1 Explanation: 1. Hypovolemic shock is caused by a decrease in intravascular volume. In hypovolemic shock, the venous blood returning to the heart decreases, and ventricular fills drops. As a result, stroke volume, cardiac output, and blood pressure decrease. Hypovolemic shock affects all body systems. 2. Cardiogenic shock occurs when the heart's pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion. 3. Patients at risk for developing infections leading to septic shock include those who are hospitalized, have debilitating chronic illnesses, or have poor nutritional status. Septic shock does not usually present in a patient with a traumatic injury. 4. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings. Page Ref: 307 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

33 ..

34) The nurse suspects that a patient with a myocardial infarction is developing cardiogenic shock. What manifestation did the nurse assess to come to this conclusion? 1. Jugular vein distention 2. Warm extremities 3. Laryngospasm 4. Urticaria Answer: 1 Explanation: 1. Jugular vein distention is seen in cardiogenic shock. 2. Warm extremities are seen in early septic shock and anaphylactic shock. 3. Laryngospasm is seen in anaphylactic shock. 4. Urticaria is seen in anaphylactic shock. Page Ref: 308 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

34 ..

35) A patient is diagnosed with a pneumothorax. Which type of shock is this patient at risk for developing? 1. Obstructive 2. Hypovolemic 3. Cardiogenic 4. Neurogenic Answer: 1 Explanation: 1. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. One cause of obstructive shock is impaired diastolic filling, as seen in a pneumothorax. 2. Hypovolemic shock is seen in patients with a low circulating blood volume. 3. Cardiogenic shock can occur in patients who have experienced a myocardial infarction. 4. Neurogenic shock can occur in patients with spinal cord injuries. Page Ref: 309 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

35 ..

36) An older patient is diagnosed with E. coli in the bloodstream. If not treated, this patient is at risk for developing which types of shock? 1. Distributive 2. Obstructive 3. Hypovolemic 4. Anaphylactic Answer: 1 Explanation: 1. Distributive shock includes several types of shock that result from widespread vasodilatation and decreased peripheral resistance. As the blood volume does not change, relative hypovolemia results. One example of distributive shock is septic shock. Septic shock is a subset of sepsis where there are underlying circulatory and cellular/metabolic abnormalities that are profound enough to substantially increase mortality and is most often the result of gram-negative bacterial infections such as E. coli. 2. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. 3. Hypovolemic shock occurs with a decrease in circulating blood volume. 4. Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction. Page Ref: 309 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.3 Outline the pathophysiology of the different types of shock and the effects of shock on body systems. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

36 ..

37) A patient is admitted with severe facial injuries from a motor vehicle crash. For what should the nurse first assess this patient? 1. Signs of stridor, cough, or respiratory distress 2. Blood pressure 3. Need for suctioning 4. Loose teeth or obvious problems with the mouth Answer: 1 Explanation: 1. The patient with multiple injuries is at great risk for developing airway obstruction and apnea. All of the choices are important; however, the most important assessment is for a patent and maintainable airway. The nurse should assess for manifestations of airway obstruction including stridor, tachypnea, bradypnea, cough, cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness. 2. The blood pressure can be assessed after the patient is assessed for respiratory distress. 3. The need for suctioning can be determined after it has been determined that the patient has an adequate airway. 4. Assessment of the mouth can occur after determining that the patient has an adequate airway. Page Ref: 298 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

37 ..

38) A female patient who was raped 6 months ago seeks treatment for posttraumatic stress disorder. Which manifestation should the nurse expect to assess in this patient? 1. Severe nightmares related to the event 2. Absence of anger or shock 3. Avoiding drug and alcohol use 4. Has a very supportive family Answer: 1 Explanation: 1. Posttraumatic stress disorder is an intense, sustained emotional response to a disastrous event. It is characterized by emotions that range from anger to fear, and by flashbacks or psychic numbing. In the initial stage, the patient can be calm or might express feelings of anger, disbelief, terror, and shock. In the long-term phase, which begins anywhere from a few days to several months after the event, the patient often experiences flashbacks and nightmares of the traumatic event. The patient also might call on ineffective coping mechanisms, such as alcohol or drugs, and withdraw from relationships. 2. Feelings of anger and shock are associated with posttraumatic stress disorder. 3. Patients who experience posttraumatic stress disorder are more prone to using alcohol or drugs. 4. These patients usually withdraw from relationships. Page Ref: 300 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Crisis Intervention Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

38 ..

39) The nurse is planning care for a patient diagnosed with shock. Which intervention should the nurse include to address this patient's problem of anxiety? 1. Reducing stimuli and medicating for pain 2. Assessing blood pressure and heart rate 3. Monitoring central venous pressure 4. Assessing bowel sounds Answer: 1 Explanation: 1. Interventions appropriate for the problem of anxiety include reducing stimuli, which is calming and facilitates rest, and medicating for pain because pain precipitates or aggravates anxiety. 2. Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. 3. Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. 4. Assessing bowel sounds would be appropriate for a problem with cardiac output. Page Ref: 315-316 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Stress Management Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

39 ..

40) The nurse identifies the problem of impaired physical mobility in a patient hospitalized with traumatic injuries. Which intervention should the nurse identify as appropriate for this patient? 1. Provide active range-of-motion exercises to affected extremities every 8 hours. 2. Turn and reposition every hour. 3. Remove anti-embolic stockings for 3 hours every shift. 4. Administer tetanus toxoid. Answer: 1 Explanation: 1. The patient with impaired physical mobility should have active range-of-motion exercises to the affected extremities once every 8 hours. 2. The patient should be turned and repositioned every 2 hours. 3. Anti-embolic stockings should be removed for 1 hour every shift. 4. Administering the tetanus toxoid would be appropriate for reducing the risk for infection. Page Ref: 299 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

40 ..

41) A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess? Select all that apply. 1. Cutaneous 2. Abrasion 3. Laceration 4. Contusion 5. Keloid Answer: 2, 3, 4 Explanation: 1. Cutaneous is a term used to refer to the integument, not to trauma to the skin. 2. Abrasions, or partial-thickness denudations of an area of integument, generally result from falls or scrapes. 3. Lacerations are open wounds that result from sharp cutting or tearing. 4. Contusions, or superficial tissue injuries, result from blunt trauma that causes the breakage of small blood vessels and bleeding into the surrounding tissue. 5. A keloid is a type of scar. Page Ref: 291 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.1 Outline the components and types of trauma and the effects of traumatic injury on the body. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients experiencing trauma and shock.

41 ..

42) A trauma patient is being assessed with the Trauma and Injury Severity Score (TRISS) system. What assessment data should the nurse use with this scoring system? Select all that apply. 1. Diastolic blood pressure 2. Heart rate 3. Glasgow coma scale 4. Systolic blood pressure 5. Respiratory rate Answer: 3, 4, 5 Explanation: 1. Diastolic blood pressure is not included in the TRISS System. 2. Heart rate is not included in the TRISS System. 3. The TRISS score uses age, type of trauma, systolic blood pressure, respiratory rate, injury severity score, and Glasgow Coma Scale score to predict survival based on a weighted algorithm that trauma centers input into a computer. 4. The TRISS score uses age, type of trauma, systolic blood pressure, respiratory rate, injury severity score, and Glasgow Coma Scale score to predict survival based on a weighted algorithm that trauma centers input into a computer. 5. The TRISS score uses age, type of trauma, systolic blood pressure, respiratory rate, injury severity score, and Glasgow Coma Scale score to predict survival based on a weighted algorithm that trauma centers input into a computer. Page Ref: 293 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

42 ..

43) A patient is to receive nitroglycerin (Tridil) 10 mcg/min. The medication strength is 50 mg/250 mL. The IV rate should be ________ mL/min. Record your answer rounding to the nearest whole number. Answer: 3 Explanation: 10 mcg is changed to 0.01 mg by moving the decimal three places to the left. 0.01 mg/min = x mL/h 0.01 mg/min × 60/60 = 0.6 mg/60 min = 0.6 mg/1h 0.6 mg/h = x mL/h 0.6 mg/x mL = 50 mg/250 mL x=3 Page Ref: 312 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

43 ..

44) A patient has received 145 mL of blood and complains of chills. For what should the nurse assess this patient? Select all that apply. 1. Bradypnea 2. Urticaria 3. Fever 4. Hypertension 5. Lumbar pain Answer: 2, 3, 5 Explanation: 1. Reduced respiratory rate is not a manifestation of a hemolytic blood reaction. 2. Urticaria is a manifestation of a hemolytic blood reaction. 3. Fever is a manifestation of a hemolytic blood reaction. 4. Hypertension is not a manifestation of a hemolytic blood reaction. 5. Lumbar pain is a manifestation of a hemolytic blood reaction. Page Ref: 297 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients experiencing trauma and shock.

44 ..

45) A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment finding indicates to the nurse that the infusion rate should be reduced? Select all that apply. 1. Prothrombin time of 13.5 seconds 2. Jugular vein distention 3. Tenting of the skin 4. Increased central venous pressure 5. Auscultation of crackles and wheezes Answer: 2, 4, 5 Explanation: 1. A prothrombin time of 13.5 seconds is within normal range. 2. Jugular vein distention indicates circulatory overload and pulmonary edema. 3. Tenting of the skin would indicate dehydration and the need for more fluid replacement. 4. Increased central venous pressure indicates circulatory overload and pulmonary edema. 5. Crackles and wheezes indicate circulatory overload and pulmonary edema. Page Ref: 313 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

45 ..

46) Emergency personnel are preparing to complete an on-the-scene rapid assessment of a victim of a motor vehicle crash. In which order should the victim's assessment be completed? Place the assessments in order of importance. Choice 1. Assessment for obvious injuries Choice 2. Vital signs and patient history Choice 3. Airway and breathing assessment Choice 4. Circulation assessment Choice 5. Level of consciousness and pupillary function Answer: 3, 4, 5, 1, 2 Explanation: Choice 1. The fourth step is to assess for obvious injuries. Choice 2. The last step is to assess vital signs and complete a patient history. Choice 3. The first step is to assess the patient's airway and breathing. Choice 4. The second step is to assess the patient's circulatory system. Choice 5. The third step is to assess the patient's level of consciousness and pupillary function. Page Ref: 293 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

46 ..

47) A patient receiving a unit of packed red blood cells for hypovolemic shock is demonstrating signs of a transfusion reaction. In which order should the nurse provide care to this patient? Place in order the steps of the process. Choice 1. Stop the transfusion and notify the healthcare provider Choice 2. Compare the blood slip with the unit of blood Choice 3. Assess vital signs and associated manifestations Choice 4. Save the blood bag and tubing for laboratory analysis Choice 5. Collect urine and venous blood samples according to policy Answer: 1, 3, 2, 4, 5 Explanation: Choice 1. The first step is to immediately stop the infusion and notify the healthcare provider. Choice 2. The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. Choice 3. The second step is to assess vital signs and assess for other manifestations. Choice 4. The fourth step is to save the blood bag and any remaining blood for return to the laboratory for testing to determine the cause of the reaction. Choice 5. The fifth step is to follow organizational policy for collecting urine and venous blood samples. Page Ref: 297 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

47 ..

48) The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment finding led the nurse to come to this conclusion? Select all that apply. 1. Combative behavior 2. Absent breath sounds in left lower lobe 3. Pedal and popliteal pulses weak and irregular 4. Temperature raised 2 degrees over the last 4 hours 5. Oxygen saturation 86% on 40% oxygen face mask Answer: 1, 2, 5 Explanation: 1. An early sign of an ineffective airway is a change in the patient's behavior. If the patient becomes combative, the nurse immediately assesses the effectiveness of the airway. 2. Absent breath sounds can indicate airway obstruction. 3. Changes in lower extremity pulses indicate an alteration in perfusion. 4. Changes in body temperature indicate an infectious process. 5. Oxygen saturation is a measurement of airway effectiveness. Oxygen flow should be adjusted to keep saturation level between 94% and 100%. Page Ref: 298-299 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11.2 Describe the pathophysiology and manifestations of traumatic injury, and outline the interprofessional care, nursing care, and transitions of care for patients experiencing trauma. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

48 ..

49) An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medication should the nurse anticipate providing to this patient? Select all that apply. 1. Diuretics 2. Antibiotics 3. Epinephrine 4. Beta2-agonists 5. Antihistamine Answer: 3, 4, 5 Explanation: 1. Diuretics are used to increase urine output after fluid replacement has been initiated. 2. Antibiotics are used to suppress organisms in septic shock. 3. Epinephrine is used to treat anaphylactic shock. 4. Beta2-agonists are used to treat anaphylactic shock. 5. Antihistamines are used to treat anaphylactic shock. Page Ref: 312 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; 1. Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 2. Consider intraprofessional care for patients experiencing trauma and shock.

49 ..

50) A patient with thoracic injuries sustained in a multivehicle crash is demonstrating an alteration in perfusion. What should the nurse do to help this patient? Select all that apply. 1. Auscultate lung sounds. 2. Measure blood pressure. 3. Measure central venous pressure. 4. Reduce rate of intravenous fluids. 5. Assess for jugular vein distention. Answer: 1, 2, 3, 5 Explanation: 1. For an alteration in perfusion, the nurse should auscultate lung sounds. 2. For an alteration in perfusion, the nurse should measure blood pressure. 3. For an alteration in perfusion, the nurse should measure current central venous pressure. 4. Reducing intravenous fluids could exacerbate the problem. 5. For an alteration in perfusion, the nurse should assess for jugular vein distention. Page Ref: 315 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 11.4 Describe the pathophysiology and manifestations of shock, and outline the interprofessional care, nursing care, and transitions of care for patients with shock. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients experiencing trauma and shock.

50 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 12 Nursing Care of Patients with Infections and Inflammation 1) A patient has an elevated basophil count. What should this laboratory value indicate to the nurse? 1. The patient is experiencing an acute hypersensitivity reaction. 2. The patient has a gastrointestinal infection. 3. The patient is fighting a tuberculosis infection. 4. The patient is fighting cancer. Answer: 1 Explanation: 1. Basophils are not phagocytic and contain proteins and chemicals such as heparin, histamine, bradykinin, serotonin, and leukotrienes that are released into the bloodstream during an acute hypersensitivity reaction or stress response. 2. Eosinophils are found in large numbers in the respiratory and gastrointestinal tracts, where they are thought to be responsible for protecting the body from parasitic worms, including tapeworms, flukes, pinworms, and hookworms. 3. Monocytes and macrophages activate the immune response against chronic infections such as tuberculosis, viral infections, and certain intracellular parasitic infections. 4. Dendritic cells activate T cells against cancer. Page Ref: 324 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

1 ..

2) The nurse is caring for a patient recovering from a splenectomy. What should the nurse realize will occur regarding this patient's immunity? 1. The liver and bone marrow will take over the spleen's functions. 2. The patient will need to avoid infections every day of his life. 3. The patient will have edematous lymph glands throughout his body. 4. The thymus gland will take over the spleen's functions. Answer: 1 Explanation: 1. The spleen is not essential for life. If it is removed, the liver and bone marrow will take over its functions. 2. Having the spleen removed does not mean that the patient will need to avoid infections every day of his life. 3. Having the spleen removed does not mean that the patient will have edematous lymph glands throughout his body. 4. The thymus gland will not take over the spleen's functions. Page Ref: 326 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

2 ..

3) A patient's white blood cell (WBC) count is 11,000/mm3. What does the nurse understand this value to represent? 1. Total number of circulating leukocytes 2. Total number of circulating neutrophils 3. Total number of circulating eosinophils 4. Total number of circulating basophils Answer: 1 Explanation: 1. In laboratory tests, the WBC count indicates the total number of circulating leukocytes. 2. The differential identifies the total number of circulating neutrophils. 3. The differential identifies the total number of circulating eosinophils. 4. The differential identifies the total number of circulating basophils. Page Ref: 342 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

3 ..

4) A patient sustains fractures to the ribs, both femurs, and one humerus. What should the nurse include when planning care for this patient's immunologic status? 1. Monitor complete blood count daily. 2. Limit food rich in iron. 3. Perform passive range of motion to unaffected extremities. 4. Keep on bed rest. Answer: 1 Explanation: 1. Bone marrow is soft organic tissue found in the hollow cavity of the long bones, particularly the femur and humerus, as well as the flat bones of the pelvis, ribs, and sternum. Bone marrow produces and stores hematopoietic stem cells, from which all cellular components of the blood are derived. Because the patient has fractured ribs, femurs, and one humerus, the nurse should monitor the patient's complete blood count daily. 2. Food rich in iron should not be limited. 3. Performing passive range of motion to the unaffected extremities will not improve the patient's immunologic status. 4. Staying on bed rest will not improve the patient's immunologic status. Page Ref: 326 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

4 ..

5) A patient is diagnosed with a positive tuberculosis skin test. What should the nurse realize causes this type of response? 1. Performing a cell-mediated inflammatory response 2. Promoting phagocytosis of the antigen by neutrophils 3. Clumping antigens to form a noninvasive aggregate 4. Coating the antigen with antibodies Answer: 1 Explanation: 1. The cell-mediated response has memory, and subsequent exposures to an antigen result in a more rapid and effective inflammatory response. This memory provides the basis for skin testing. A patient previously exposed to tuberculosis develops a more pronounced inflammatory response when minute amounts are injected under the skin. 2. This is a characteristic of an antibody-mediated immune response. 3. This is a characteristic of an antibody-mediated immune response. 4. This is a characteristic of an antibody-mediated immune response. Page Ref: 335 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.

5 ..

6) A patient is happy that a spouse did not catch a cold that other family members have experienced. Which immune response is the spouse most likely experiencing? 1. Helper T cells had a memory of a previous exposure to the same virus that caused the patient's illness. 2. Suppressor T cells killed the virus. 3. The virus was eliminated via phagocytosis by neutrophils. 4. Cytokines were released. Answer: 1 Explanation: 1. Helper T cells stimulate B cells to make antibodies to specific antigens. These cells then have a "memory" of exposure, which will lead to a quick response if another exposure occurs. In this scenario, the spouse must have had a previous exposure to the same virus that caused other family members' colds, and because of this "memory," the body immediately responded by eliminating the cold virus. 2. Suppressor T cells stop the immune process and would not kill virus cells. 3. Phagocytosis of the virus by neutrophils is an antibody-mediated response. This scenario describes a cell-mediated immune response. 4. Cytokines are chemical messengers produced by cells to either increase the flow of white blood cells to a body area or coat an antigen to encourage phagocytosis. Page Ref: 333 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

6 ..

7) The nurse is caring for a patient diagnosed with a lung infection. Which immunoglobulin level should the nurse expect to be elevated in this patient? 1. Immunoglobulin A 2. Immunoglobulin M 3. Immunoglobulin E 4. Immunoglobulin D Answer: 1 Explanation: 1. Immunoglobulins are made in response to a primary or initial exposure to an antigen. Immunoglobulin A is most commonly found in secretions, and its major function is to protect the eyes, mouth, nose, gastrointestinal tract, and lungs from diseases caused by viruses and bacteria. For the patient with a lung infection, this immunoglobulin level will likely be the highest. 2. Immunoglobulin M is the first antibody produced in the primary immune response and is first produced during embryonic development. 3. Immunoglobulin E is the primary antibody in the allergic response. 4. Immunoglobulin D is the cell that is least understood and is present in small quantities in the blood. Page Ref: 331 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

7 ..

8) A patient who just delivered a newborn baby is concerned that the baby will "catch" a cold from a healthcare provider who was coughing and sneezing in the delivery room. How should the nurse respond? 1. "The baby has some protection from infections from the time of birth." 2. "The baby should be isolated." 3. "I will be sure to have everyone check the baby's temperature for signs of an infection." 4. "The healthcare provider should not have been participating in your care." Answer: 1 Explanation: 1. Immunoglobulin G is the only immunoglobulin to cross the placental barrier and provide immune protection to the neonate. 2. The baby does not need to be isolated. 3. The baby's temperature will be checked routinely and evaluated for signs of infection. 4. This response would be inappropriate. Page Ref: 331 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

8 ..

9) The nurse is concerned that a patient is exhibiting signs and symptoms of inflammation. What did the nurse assess to come to this conclusion? Select all that apply. 1. Leg edema 2. Severe pain from swelling 3. Severe erythema of leg 4. Leg cool to the touch 5. Decreased peripheral pulses Answer: 1, 2, 3 Explanation: 1. Leg edema is caused by accumulated fluid at the site. 2. Severe pain from tissue swelling is caused by chemical irritation of the nerve endings. 3. Severe erythema is a sign of inflammation. 4. Cool skin is not a sign of inflammation. 5. A change in pulse is not a sign of inflammation. Page Ref: 340 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

9 ..

10) An older patient has a small pressure ulcer on the coccyx. What should the nurse do to promote healing of the wound? 1. Encourage high-protein food choices in the diet. 2. Limit carbohydrate intake. 3. Encourage a high intake of vitamin E. 4. Restrict caloric intake. Answer: 1 Explanation: 1. A lack of protein prolongs inflammation and impairs the healing process. The nurse should encourage high-protein food choices in the diet. 2. If carbohydrates are limited, the body will use protein to meet caloric needs. This would impair healing. 3. Vitamin E is not identified as a vitamin to promote wound healing. 4. Restricting caloric intake could further compromise this patient and delay healing. Page Ref: 341 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

10 ..

11) The nurse believes that a patient is experiencing a systemic reaction associated with an inflammatory response. Which assessment finding supports this nurse's belief? 1. Edematous groin lymph nodes 2. Erythema 3. Edema 4. Pain Answer: 1 Explanation: 1. Systemic reactions associated with an inflammatory response include an increase in the size of lymph nodes, fever, loss of appetite, fatigue, and leukocytosis. 2. Erythema indicates a local reaction. 3. Edema indicates a local reaction. 4. Pain indicates a local reaction. Page Ref: 341 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

11 ..

12) A patient recovering from knee surgery has a surgical infection. What finding indicates that the patient is experiencing a systemic reaction? Select all that apply. 1. WBC 14,200 mm3 2. Lymph node swelling 3. Erythema 4. Pain at the surgical site 5. Respiratory rate of 16 Answer: 1, 2 Explanation: 1. An elevated white blood cell count is an indication of a systemic reaction to the infection. 2. Systemic responses to inflammation include lymph node swelling (lymphadenopathy) due to the proliferation of macrophages within the nodes in response to microorganisms in the lymph. 3. Erythema is a local reaction to an infection. 4. Pain is a local reaction to an infection. 5. A respiratory rate of 16 is a normal finding. Page Ref: 341 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

12 ..

13) The nurse is concerned that an older patient could be at risk for developing an infection. Which intervention led to this conclusion? 1. Urinary catheterization 2. Applying anti-embolism stockings 3. Ambulation with the assistance of a walker 4. Medicating for pain as needed prior to physical therapy Answer: 1 Explanation: 1. Invasive procedures and altered immune defenses are the main factors contributing to hospital-acquired infection. Urinary catheterization is a major cause. 2. The use of anti-embolism stockings is not associated with the onset of nosocomial infections. 3. Ambulation with a walker is not associated with nosocomial infections. 4. Medicating for pain is not associated with nosocomial infections. Page Ref: 350 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

13 ..

14) The nurse is planning care for a patient at risk for developing an infection. Which intervention should the nurse include in the plan of care? 1. Washing the hands prior to providing care to the patient 2. Providing prophylactic antibiotic therapy as prescribed 3. Wearing a mask when caring for the patient 4. Wearing a gown and gloves when changing the patient's linen Answer: 1 Explanation: 1. Prevention is the most important control measure against nosocomial infections. The pathogens causing these infections are transmitted primarily by contact with hospital personnel and contaminated inanimate objects. Effective hand hygiene is the single most important measure in infection control. 2. Prophylactic antibiotic therapy could lead to the growth of bacteria-resistant microorganisms. 3. The use of a mask is not needed to prevent the onset of infection in the patient. 4. The use of a gown and gloves is not needed to prevent the onset of infection in the patient. Page Ref: 339 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

14 ..

15) A patient has been intubated to receive care in the intensive care unit. Which type of infection is this patient at risk for developing? 1. Ventilation-assisted pneumonia 2. Urinary tract infection 3. Surgical wound infection 4. Intravenous site infection Answer: 1 Explanation: 1. Ventilator-associated pneumonia (VAP) is pneumonia occurring after 48 to 72 hours of mechanical ventilation. 2. There is not enough information to determine if the patient is at risk for developing a urinary tract infection. 3. There is not enough information to determine if the patient has a surgical wound. 4. Although intravenous site infections can occur, the risk for another type of infection is greater for this patient. Page Ref: 348-349 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

15 ..

16) A patient is diagnosed with an antibiotic-resistant infection. Which action should the nurse take to reduce the spread of this infection? 1. Isolate the supplies used to care for this patient. 2. Transfer the patient to a semiprivate room. 3. Limit exposure to this patient. 4. Restrict visitors and plan activities to coincide with meal delivery times. Answer: 1 Explanation: 1. Standard precautions, hand hygiene, and use of carefully selected antibiotics are critical actions for preventing the spread of these infections. Equipment such as stethoscopes, blood pressure cuffs, and thermometers should be restricted to use by each patient identified with one of these diseases. The nurse should isolate the supplies used to care for this patient. 2. Transferring the patient to a semiprivate room would not reduce the spread of infection. 3. Limiting exposure to this patient could compromise the patient's care. 4. Restricting visitors and planning activities to coincide with meal delivery times would compromise this patient's care. Page Ref: 349 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

16 ..

17) The nurse is instructing a patient on ways to prevent the onset of infection. What should the nurse include in these instructions? 1. Wash the hands after using disposable tissues for nasal secretions. 2. Reuse disposable razors. 3. Take prescribed antibiotics until symptoms subside. 4. Do not limit interactions with people or crowds. Answer: 1 Explanation: 1. One way to reduce the spread of infection is to use disposable tissues for nasal secretions and wash the hands afterwards. 2. Reusing disposable razors could cause an infection. 3. Antibiotics should be taken as prescribed, not until symptoms subside. 4. Limiting interactions with people and crowds is one way to reduce the spread of infection. Page Ref: 359 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their cares | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

17 ..

18) A patient is receiving intravenous vancomycin for the treatment of Clostridium difficile. Why should the nurse assess the patient for flushing, tachycardia, and hypotension during the infusion of this medication? 1. Identify red man syndrome 2. Recognize the ototoxicity effect 3. Prevent a superinfection 4. Begin treatment for hives Answer: 1 Explanation: 1. Vancomycin inhibits cell wall synthesis and is used for serious infections. It is only effective against gram-positive bacteria, especially Staphylococcus aureus and Staphylococcus epidermidis. The nurse should infuse this medication slowly over 60 minutes or more to avoid "red man" syndrome, which is characterized by erythematous rash, flushing, tachycardia, and hypotension. 2. Vancomycin is not associated with ototoxicity. 3. Vancomycin is not associated with superinfection. 4. Vancomycin is not associated with hives. Page Ref: 354 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

18 ..

19) A patient is prescribed a trough blood level to evaluate the therapeutic effect of an antibiotic. When should the nurse schedule this blood test to be drawn? 1. A few minutes before the next scheduled dose of medication 2. 1-2 hours after the oral administration of the medication 3. 30 minutes after the intravenous administration of the medication 4. During the infusion of the antibiotic Answer: 1 Explanation: 1. Antibiotic peak and trough levels monitor therapeutic blood levels of the prescribed medication. The trough level is drawn a few minutes before the next scheduled dose. 2. The peak level would be 1-2 hours after the oral administration of a medication. 3. The peak level would occur 30 minutes after the intravenous administration of a medication. 4. Drawing the blood during the infusion of the antibiotic would not yield either a peak or a trough level. Page Ref: 351 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

19 ..

20) A patient is diagnosed with active tuberculosis. For which type of isolation should the nurse prepare this patient? 1. Airborne 2. Standard 3. Droplet 4. Contact Answer: 1 Explanation: 1. Airborne precautions are instituted for the patient with pulmonary tuberculosis. The patient will be in a private room with special ventilation, and masks with filter respirators will be used by everyone entering the room. 2. Standard precautions are infection control practices used for every patient. 3. Droplet precautions reduce the risk of droplet transmission of infectious agents. Droplet transmission involves contact of conjunctivae of the eyes or mucous membranes of the nose or mouth with large-particle droplets generated during coughing, sneezing, talking, or procedures such as suctioning. 4. Contact precautions reduce the risk of transmission by direct or indirect contact. Direct contact transmission involves skin-to-skin contact and physical transfer of organisms. Page Ref: 340 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

20 ..

21) The nurse needs to obtain a sputum specimen for culture and sensitivity from a patient. When should the nurse obtain this specimen? 1. Before the first dose of antibiotics is administered 2. Immediately after the first dose of antibiotic is administered 3. 30 minutes after the first dose of antibiotics is administered 4. During administration of the first dose of antibiotics Answer: 1 Explanation: 1. When collecting a specimen for culture and sensitivity, the nurse should collect the specimen before the first dose of antibiotics is administered to ensure adequate organisms for culture. 2. If the specimen were collected after the first dose of the antibiotic, there might not be sufficient microorganisms available for culture. 3. If the specimen were collected after the first dose of the antibiotic, there might not be sufficient microorganisms available for culture. 4. It would not be appropriate to obtain the first specimen as the first dose of antibiotics is being administered. Page Ref: 350 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.

21 ..

22) A patient develops hyperthermia related to a diagnosis of pneumonia. Which interventions should the nurse perform to help with this problem? Select all that apply. 1. Reduce the temperature of the room. 2. Administer antipyretic medications as prescribed. 3. Promote frequent rest periods. 4. Administer ice packs. 5. Restrict fluids. Answer: 1, 2, 3 Explanation: 1. Reducing the temperature of the room is one way to promote body cooling without causing the patient to shiver. 2. Antipyretic medications lower the body temperature. 3. Rest will reduce metabolic demands on the body. 4. Ice packs could cause shivering and should be used with caution. 5. Restricting fluids could cause the body temperature to rise. The patient will need additional fluids. Page Ref: 358-359 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

22 ..

23) The nurse needs to change a patient's abdominal wound dressing. Which precaution should the nurse follow during this dressing change? 1. Standard 2. Contact 3. Droplet 4. Airborne Answer: 1 Explanation: 1. Standard precautions are used on all patients, regardless of whether they have a known infectious disease. Standard precautions are used by all healthcare workers who have direct contact with patients or with their body fluids. Because the patient has an abdominal dressing, the nurse will use standard precautions. 2. The patient does not have a diagnosed wound infection, so contact precautions are not necessary. 3. The patient does not have a diagnosed disorder that would necessitate droplet precautions. 4. The patient does not have a diagnosed disorder that would necessitate airborne precautions. Page Ref: 339 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

23 ..

24) The nurse has completed caring for a patient's indwelling urinary catheter. What should the nurse do after clearing used supplies and removing the gloves? 1. Wash the hands with soap. 2. Document the care provided. 3. Prepare medications for the patient. 4. Discuss with the nursing assistant additional care needs for the patient. Answer: 1 Explanation: 1. After completing procedures, the nurse should wash the hands with soap and water. This is the most effective way to reduce the spread of infection. 2. Another step should be completed first. 3. Another step should be completed first. 4. Another step should be completed first. Page Ref: 359 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

24 ..

25) A patient is receiving an aminoglycoside. Which finding should the nurse immediately report? Select all that apply. 1. History of allergy to penicillin 2. Weight gain of 5 kg in 2 days 3. Symptoms of vertigo 4. Fluid intake below 2000 mL/day 5. New prescription for IV furosemide (Lasix) Answer: 2, 3, 5 Explanation: 1. A history of allergy to penicillin would apply to cephalosporins. 2. Aminoglycosides are nephrotoxic. A sudden weight gain indicates possible kidney damage and should be immediately reported. 3. The nurse should report the patient's complaints of vertigo because aminoglycosides are ototoxic. 4. A patient on fluoroquinolones or sulfonamides must maintain a fluid intake of 2000 to 3000 mL/day. 5. Furosemide is ototoxic and should not be administered with other ototoxic medications such as aminoglycosides. Page Ref: 354 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.

25 ..

26) A patient is prescribed to receive linezolid (Zyvox) 600 mg intravenously twice a day. The medication is prepared as 600 mg/300 mL with directions to give over 120 minutes. An infusion set that administers 15 gtts/mL is available. How many drops of medication per minute should the nurse set this infusion pump to deliver? Record your answer rounding to the nearest whole number. Answer: 38 Explanation: 300 mL × 15 gtt/mL/120 min 4500/120 = 37.5 37.5 rounds out to 38 gtt/min Page Ref: 354 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.

26 ..

27) The nurse is reviewing the antibody-mediated immune response with a patient experiencing a first exposure to an antigen. What event should the nurse explain that occur in this immune response? Select all that apply. 1. Antigen-binding fragment (Fab) decreases. 2. An antigen begins the process of reaction. 3. Memory B cells and plasma cells are cloned. 4. T helper cells are stimulated. 5. Cell division and differentiation occur. Answer: 2, 3, 5 Explanation: 1. The antigen-antibody reaction includes a binding of the antigen (Fab). 2. The primary response begins with the initial encounter with an antigen. 3. Memory B cells and plasma cells are cloned after the initial encounter with the antigen. 4. T cells take part in cellular immunity. 5. During initial exposure to an antigen, the antigen is bound to the antibody, which stimulates cell growth, division, and differentiation. Page Ref: 332 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

27 ..

28) The nurse suspects that a patient is experiencing a local inflammatory response. What finding would support this conclusion? Select all that apply. 1. Temperature under 96.8°F (36°C) 2. Heat at the site of injury 3. Increased platelets 4. Edema 5. Functional impairment Answer: 2, 4, 5 Explanation: 1. The temperature may be increased or decreased in response to a systemic infection. 2. One sign of a local inflammatory response is warmth. 3. The platelet response would be related to a systemic event. 4. One sign of a local inflammatory response is edema. 5. One sign of a local inflammatory response is functional impairment. Page Ref: 340 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

28 ..

29) A patient has been prescribed cefuroxime (Ceftin). What should the nurse teach the patient about this medication? Select all that apply. 1. Take on an empty stomach. 2. Avoid alcohol. 3. Report any hearing loss. 4. Eat yogurt daily. 5. Complete the prescription. Answer: 1, 4, 5 Explanation: 1. Cefuroxime (Ceftin) is a cephalosporin and must be taken on an empty stomach. 2. This cephalosporin is not identified as causing alcohol intolerance. 3. Hearing loss applies to the aminoglycosides. 4. Yogurt helps prevent intestinal superinfection. 5. The entire prescription must be completed in order to be effective. Page Ref: 353 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

29 ..

30) A patient who has never experienced a reaction to a bee sting develops intense edema and redness at the site of a sting. For which type of immune response should the nurse provide care for this patient? 1. Mobilization of lymphocytic memory T cells 2. Activation of granulocytes 3. Creation of neutrophils 4. Circulation of eosinophils Answer: 1 Explanation: 1. T lymphocytes mature into active helper T cells, cytotoxic T cells, or memory T cells. Memory cells stay inactive, sometimes for years, but activate immediately with subsequent exposure to the same antigen. They then proliferate rapidly and produce an intense immune response. Memory cells are responsible for providing acquired immunity. 2. Granulocytes protect against harmful microorganisms during a period of acute inflammation. 3. Neutrophils are responsible for phagocytosis and chemotaxis. 4. Eosinophils are responsible for phagocytosis and provide protection against parasites. Page Ref: 335 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

30 ..

31) A patient recovering from a splenectomy asks what impact the loss of the organ will have on the quality of life. Which response should the nurse make? 1. "You will have to avoid getting colds and flu." 2. "Your stomach will assume its functions." 3. "Your liver and bone marrow will assume its functions." 4. "A spleen is not really necessary." Answer: 3 Explanation: 1. The patient will still be able to recover from colds and the flu. 2. The stomach does not assume the spleen's functions. 3. The spleen is not essential for life. If it is removed because of disease or trauma, the liver and the bone marrow assume its functions. 4. This response does not necessarily answer the patient's question adequately. Page Ref: 326 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the healthcare team | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

31 ..

32) The nurse is caring for a patient with a localized inflammatory response. Which stage should the nurse expect the patient to experience with this response? Select all that apply. 1. Basilar 2. Cellular 3. Vascular 4. Tissue repair 5. Keratosis Answer: 2, 3 Explanation: 1. Basilar does not describe a phase of the inflammatory response. 2. The inflammatory response has two stages, one of which is the cellular response. 3. The inflammatory response has two stages, one of which is the vascular response, characterized by vasodilation and increased permeability of blood vessels. 4. Phagocytosis sets the stage for healing and tissue repair. 5. Keratosis is not a phase of the inflammatory response. Page Ref: 327 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

32 ..

33) A patient with an inflammatory response is prescribed a nonsteroidal anti-inflammatory drug (NSAID). For which reason should the nurse suspect the patient was prescribed this medication? 1. Increase the production of histamine 2. Increase the flow of serosanguineous drainage 3. Reduce the production of serotonin 4. Reduce prostaglandin synthesis Answer: 4 Explanation: 1. Histamine production is increased by the use of an NSAID. 2. The flow of serosanguineous drainage is not associated with the actions of nonsteroidal antiinflammatory medications. 3. Serotonin is contained in the granules of basophils and is not impacted by NSAIDs. 4. Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as well as glucocorticoids, inhibit prostaglandin synthesis and thereby reduce fever, pain, and inflammation. Page Ref: 327 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

33 ..

34) A patient with a compromised immune system is admitted to the hospital with an infection. What care should the nurse expect this patient to require? 1. Early discharge to recover from the infection at home 2. Placement in a semiprivate room 3. Isolation techniques to protect the patient from further infection 4. Placement in respiratory isolation Answer: 3 Explanation: 1. Patients with suppressed or impaired immune function are more susceptible to disease and require protection from exposure to environmental elements. Discharging the patient early to recover at home could exacerbate an infection. 2. Patients with suppressed or impaired immune function are more susceptible to disease and require protection from exposure to environmental elements. Placing the patient in a semiprivate room could encourage additional infections. 3. Patients with suppressed or impaired immune function are more susceptible to disease and require protection from exposure to environmental elements. Isolation techniques should be employed to protect the patient and prevent the spread of disease. 4. The information is insufficient to determine the need for a specific type of isolation. Page Ref: 358 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

34 ..

35) One school district is not requiring vaccinations for children who are starting school. What could be the result of this decision? 1. Healthier children 2. A reduction in the number of colds and flu in the school 3. Lower school costs 4. An epidemic of an illness that could have been avoided with immunization Answer: 4 Explanation: 1. Healthier children are not the result of reduced immunization. 2. The lack of immunization will not impact the number of colds and flu outbreaks in a school system. 3. High rates of illness may increase school costs. 4. For many diseases, the potential consequences of a single disease episode on the individual and society make prevention desirable, especially for highly contagious diseases that are capable of causing epidemics. In these instances, immunization provides artificially acquired immunity. The purpose of vaccination is to establish adequate levels of antibody or memory cells to provide effective immunity. Page Ref: 335 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.

35 ..

36) A patient is having skin testing done to assess for allergies. What should the nurse identify as evidence of exposure to an antigen? 1. Itching at the site 2. Area approximately 1 mm in diameter of induration and erythema 3. Induration and erythema not evident until after 5 days 4. Area larger than 10 mm of induration and erythema Answer: 4 Explanation: 1. Itching is not a sign of exposure to an antigen. 2. An induration of at least 10 mm in diameter is a positive reaction that indicates previous exposure and sensitization to the antigen. 3. Induration and erythema typically peak at 24 to 48 hours. 4. Skin testing can assess cell-mediated immunity. A known antigen is injected intradermally. The site is then observed for induration and erythema, which typically peak at 24 to 48 hours. An induration of at least 10 mm in diameter is a positive reaction that indicates previous exposure and sensitization to the antigen. Page Ref: 335 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

36 ..

37) An older patient with a history of lung disease had a pneumococcal vaccination 10 years ago. What should be done for this patient? 1. Draw a blood culture. 2. Remind the patient that he needs a booster in 5 years. 3. Remind the patient that he does not need a flu vaccination. 4. Suggest that the patient have a pneumococcal booster during this visit. Answer: 4 Explanation: 1. A blood culture is used to diagnose the presence of an infection. 2. A single dose of this vaccine confers lifetime immunity, although repeating immunization every 5 years may be considered for high-risk patients. 3. The flu vaccine and the pneumococcal vaccine are not the same. 4. Pneumococcal vaccine is generally recommended for the same populations as influenza vaccine. A single dose of this vaccine confers lifetime immunity, although repeating immunization every 5 years may be considered for patients with chronic diseases. Page Ref: 337 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

37 ..

38) A patient who received a vaccination 2 weeks ago returns to the clinic with a wound at the inoculation site. What does the nurse realize about this patient? 1. The patient is experiencing a severe local reaction to the inoculation. 2. The patient is allergic to the inoculation. 3. The patient is scratching the inoculation site. 4. The patient is demonstrating signs of the disease that the inoculation was intended to prevent. Answer: 1 Explanation: 1. Moderate to severe local reactions may occur following administration of an immunization. Occasionally local ulcerations occur; when they do, warm, wet pack, or sterile wet-to-dry dressings may be prescribed. 2. There is inadequate information to determine if the patient has an allergy to the vaccine. 3. There is not enough information to determine if the patient has been scratching at the site. 4. It is unlikely the patient has developed the disease that the inoculation was intended to prevent. Page Ref: 337 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

38 ..

39) A patient asks the nurse how long it will be before a leg wound heals. What phase of wound healing should the nurse explain to this patient? Select all that apply. 1. Inflammation 2. Deconstruction 3. Reconstruction 4. Resolution 5. Dissolution Answer: 1, 3, 4 Explanation: 1. Inflammation is the first phase of the healing process. 2. Deconstruction is not a phase of the healing process. 3. The second phase of the healing process, known as reconstruction, may overlap the inflammatory phase. 4. The ideal result of the healing process is resolution, which is the restoration of the original structure and function of the damaged tissue. 5. Dissolution is not a phase of the healing process. Page Ref: 330 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.1 Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with infection.

39 ..

40) The nurse is assessing a patient's arm for inflammation. Which is a sign that a localized inflammatory process is occurring? Select all that apply. 1. Purulent drainage 2. Pain 3. Hyperemia 4. Erythema 5. Induration Answer: 2, 3, 4 Explanation: 1. Purulent drainage typically accompanies an infection. 2. Pain from tissue swelling and chemical irritation of nerve endings is a sign of a localized inflammatory process. 3. Increased blood flow to the injured area, causing hyperemia, is a sign of a localized inflammatory process. 4. Erythema is a sign of a local inflammatory process. 5. Induration is not a sign of a local inflammatory process. Page Ref: 340 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

40 ..

41) A patient who is recovering from an infectious process has a poor appetite. Which nutrient is of utmost importance to support the healing process? 1. Water 2. Protein 3. Carbohydrates 4. Fats Answer: 2 Explanation: 1. Water provides hydration. Hydration is needed for the body but is not the key nutrient for the promotion of healing. 2. Adequate protein is necessary for tissue healing and the production of antibodies and white blood cells (WBCs). Lack of adequate protein increases the risk of infection. 3. Carbohydrates are needed for energy. 4. Fats are a source of warmth, and the excess is stored for later use. Page Ref: 341 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

41 ..

42) A patient wants to know why an infection developed after being cut on the leg with a piece of wood, but a friend who was also cut did not. How should the nurse explain this phenomenon? 1. "Maybe the wood that cut your friend wasn't dirty and infected." 2. "You must have an autoimmune disorder." 3. "The organism found you more susceptible to infection." 4. "Your friend will get an infection too. It will just develop later." Answer: 3 Explanation: 1. There is no evidence the wood was or was not contaminated. 2. An autoimmune disorder would not cause an infection in this situation. 3. For a microorganism to cause infection, it must have disease-causing potential (virulence), be transmitted from its reservoir, and gain entry into a susceptible host. 4. There is no evidence to indicate that the friend will develop an infection. Page Ref: 346 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

42 ..

43) A patient with methicillin-resistant Staphylococcus aureus (MRSA) is no longer responding to the medication vancomycin (Vancocin). What medication might be indicated for this patient? 1. Penicillin 2. Gentamycin 3. Tetracycline 4. Linezolid Answer: 4 Explanation: 1. Penicillin is not identified as a medication to treat vancomycin-resistant S. aureus. 2. Gentamycin is not identified as a medication to treat vancomycin-resistant S. aureus. 3. Tetracycline is not identified as a medication to treat vancomycin-resistant S. aureus. 4. Linezolid (Zyvox) is the first antibiotic in a class of antibiotics called oxazolidinones. This antibiotic inhibits protein synthesis and is effective against organisms that are resistant to both vancomycin and methicillin. Because of its usefulness against those organisms, its use should be reserved for infections caused by vancomycin-resistant enterococci (VRE) and MRSA. Page Ref: 354 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with infection.

43 ..

44) A patient with an infection is prescribed a macrolide antibiotic. What should the nurse instruct the patient about taking this medication? 1. Take the medication on a full stomach. 2. Take the medication with a glass of milk. 3. Take the medication on an empty stomach. 4. Take the medication with a full glass of juice. Answer: 3 Explanation: 1. The medication should not be taken on a full stomach. 2. The medication should not be taken with a glass of milk. 3. The most commonly prescribed macrolide is erythromycin (E-mycin), which should be taken on an empty stomach and without acidic juice. 4. The medication should not be taken with juice. Page Ref: 354 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

44 ..

45) The nurse is caring for a patient under droplet precautions. What should the nurse wear when providing care to this patient? 1. Head covering and gown 2. Shoe covering and gown 3. Gloves only 4. Mask and eye protection or face shield Answer: 4 Explanation: 1. Head covering and gown are not necessary when caring for this patient. 2. Shoe covering and gown are not necessary when caring for this patient. 3. Gloves alone are not adequate protection against droplet secretions. 4. To provide care to a patient under droplet precautions, the nurse should wear a mask and eye protection or a face shield when entering the room. Page Ref: 340 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

45 ..

46) During a home visit, the nurse determines that family members would benefit from receiving the hepatitis B vaccination. Which family members did the nurse identify as being at risk for this illness? Select all that apply. 1. 29-year-old female with ovarian cysts 2. 21-year-old male with Down syndrome 3. 63-year-old male with end-stage renal disease 4. 57-year-old female newly diagnosed with diabetes mellitus 5. 32-year-old male with liver disease from acetaminophen abuse Answer: 3, 4, 5 Explanation: 1. A history of ovarian cysts does not increase the risk of contracting hepatitis B. 2. Down syndrome does not increase the risk of contracting hepatitis B. 3. Hepatitis B vaccine is recommended for people with end-stage renal disease. 4. Hepatitis B vaccine is recommended for people newly diagnosed with diabetes mellitus who are under age 60. 5. Hepatitis B vaccine is recommended for people with chronic liver disease. Page Ref: 337 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; health promotion/disease prevention | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.2 Outline the process of acquired immunity and the importance of immunizations and isolation precautions in preventing disease. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

46 ..

47) A patient being treated for a stage 3 pressure injury is demonstrating delayed healing. What information in the patient's medical record and history would explain this delay? Select all that apply. 1. The patient had total knee replacement 7 years ago. 2. The patient takes insulin for control of type 2 diabetes mellitus. 3. The patient takes acetaminophen 650 mg twice a day for arthritis pain. 4. The patient was diagnosed with peripheral vascular disease 5 years ago. 5. The patient was prescribed steroids for treatment of chronic lung condition. Answer: 2, 3, 4 Explanation: 1. A history of total knee replacement would not delay healing in this patient. 2. Chronic diseases may impair healing. High blood glucose levels impair chemotactic and phagocytic function. 3. Acetaminophen is not identified as a medication that adversely affects healing. 4. Chronic diseases may impair healing. Arterial and venous disorders impair the delivery of oxygen and nutrients to heal tissues and remove toxins, bacteria, and other waste products from the wound area. 5. Drug therapy with corticosteroids may suppress the immune and inflammatory responses and delay healing. Page Ref: 341 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with infection.

47 ..

48) The nurse is preparing instructions for a patient with an inflammation of the right lower leg. What should the nurse emphasize when teaching this patient? Select all that apply. 1. Elevate the extremity. 2. Reduce the intake of fluids. 3. Take analgesics as prescribed. 4. Increase activity to the extremity. 5. Cleanse the area with soap and water. Answer: 1, 3 Explanation: 1. Elevation promotes venous return and reduces swelling. 2. Fluid intake may or may not impact healing of the inflammation. 3. One action to reduce the pain of an inflamed area is to take analgesics as prescribed. 4. Strenuous activity or exercising an inflamed body part may increase discomfort and tissue damage. Rest should be encouraged. 5. Inflamed tissue should be cleansed gently with water, normal saline, or nontoxic wound cleansers. Soap can cause further drying and tissue damage. Page Ref: 344 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

48 ..

49) A family member asks why an older patient is experiencing frequent episodes of pneumonia. What factors should the nurse discuss when responding? Select all that apply. 1. Diminished thirst reflex 2. Diminished cough reflex 3. Less production of sputum 4. Reduced bladder contractility 5. Reduced mucociliary clearance in the lungs Answer: 2, 3, 5 Explanation: 1. Diminished thirst reflex does not directly contribute to the development of pneumonia in the older patient. 2. Because immune function declines with aging, older adults are more susceptible to infections. A diminished cough reflex reduces the clearance of respiratory secretions and increases the risk for pneumonia. 3. The older adult may produce less sputum due to decreased immune function. 4. Reduced bladder contractility in the older patient would contribute to the development of urinary tract infections. 5. Decreased mucociliary clearance reduces the clearance of respiratory secretions and increases the risk for pneumonia. Page Ref: 348 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

49 ..

50) A patient is prescribed metronidazole (Flagyl) for treatment of C. difficile. What should the nurse include when teaching the patient about this medication? Select all that apply. 1. Do not drink any alcohol while taking this medication. 2. Drink a minimum of 2-1/2 to 3 quarts of fluid every day. 3. Notify the healthcare provider if urine color changes to reddish brown. 4. Changes in mentation and coordination are expected when taking this medication. 5. Contact the healthcare provider if urination becomes painful when taking this medication. Answer: 1, 2, 5 Explanation: 1. Alcohol should not be ingested while taking this medication. A severe reaction can occur. 2. Fluid intake should be 2-1/2 to 3 quarts each day. 3. This medication may turn urine reddish brown, which is expected and not harmful. 4. The healthcare provider should be contacted about any changes in mentation or coordination. 5. The healthcare provider should be contacted if urination becomes painful. Page Ref: 355 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 12.3 Describe the pathophysiology and manifestations of inflammation and infection, and outline the interprofessional care, nursing care, and transitions of care for patients with these conditions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with infection.

50 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 13 Nursing Care of Patients with Altered Immunity 1) A patient is having a kidney transplant from a live sibling. What must have occurred for this surgery to be planned? 1. The human leukocyte antigens between the patient and sibling must be very similar. 2. The human leukocyte antigens between the patient and sibling must be very different. 3. The patient has an overactive immune system. 4. The donor has an overactive immune system. Answer: 1 Explanation: 1. Each body cell displays specific cell surface characteristics, or markers, that are unique to each person. These are known as human leukocyte antigens. The possibility of two people having the same human leukocyte antigen type is extremely remote. Some siblings have very similar patterns. In organ transplants, matching the human leukocyte antigen type as closely as possible tends to reduce the risk of rejection. 2. If the human leukocyte antigen type were different, the surgery would not be successful. 3. There is not enough information to determine if the patient has an overactive immune system. 4. There is not enough information to determine if the donor has an overactive immune system. Page Ref: 377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

1 ..

2) A patient with an incompetent immune system asks what "disease" required placement in isolation. How should the nurse respond? 1. "Because your immune system is weak, you can develop a disease. The isolation is to protect you." 2. "I will have to find out from your doctor." 3. "It's not a bad disease. The isolation is just to make sure it doesn't spread." 4. "I am sure that once your medications start to work, you won't have to remain in isolation." Answer: 1 Explanation: 1. With an incompetent immune system, the body is unable to defend itself against invading microorganisms. The purpose of isolation is to protect the patient from developing or picking up a disease from someone else. 2. The nurse does not need to ask the healthcare provider about the patient's isolation. 3. The patient does not have a specific disease that might spread. 4. The patient may be on medication; however, it is not to treat a specific disease. Page Ref: 383 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

2 ..

3) A patient reports having the "common cold" at least three times a year but now cannot remember when the last one occurred. What should the nurse realize this patient is describing? 1. Healthy B cell functioning 2. Healthy helper T cell functioning 3. T cell secretion of antibodies 4. Healthy regulator T cell functioning Answer: 1 Explanation: 1. B cells produce antibodies, also known as immunoglobulins, that inactivate an invading antigen. Memory cells "remember" an antigen, and, when exposed to it a second time, immediately initiate the immune response. 2. Another type of lymphocyte is responsible for this phenomenon. 3. T cells do not secrete antibodies. 4. T cells are subdivided into effector cells and regulator cells. Regulator T cells are divided into two subsets known as helper T cells and suppressor T cells. In addition to destroying viruses within cells marked as "nonself," cytotoxic T cells also attack malignant cells and are responsible for the rejection of transplanted organs and grafted tissues. Page Ref: 365 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1 Review the normal immune system function, including selfrecognition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

3 ..

4) An older patient reports developing pneumonia easily; however, a spouse of the same age rarely "gets sick." How should the nurse respond? 1. "Not everyone's immune system is the same, regardless of their age." 2. "Your spouse must be doing something that you're not doing." 3. "Maybe your spouse just doesn't tell you about being sick." 4. "It's just a matter of time. Your spouse will have the same illnesses you do." Answer: 1 Explanation: 1. Immune function declines with aging. External factors, such as nutritional status and the effects of chemical exposure, ultraviolet radiation, and environmental pollution, affect the older adult's immune status. Internal factors affect it as well, including genetics, the function of the neurologic and endocrine systems, chronic and prior illnesses, and individual anatomic and physiologic variations. These influences make it difficult to determine the effect of aging on the immune system. In some older individuals, the immune system is as effective as that of younger persons. 2. The nurse should not say that the patient's spouse is doing something that the patient is not doing. 3. The nurse should not say that the spouse might not be telling the patient about being ill. 4. The nurse has no way of knowing if the spouse's immune system is going to change or when. Page Ref: 365 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.1 Review the normal immune system function, including selfrecognition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

4 ..

5) A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee. Which type of hypersensitivity reaction is this patient most likely experiencing? 1. Type I IgE-mediated hypersensitivity 2. Type II cytotoxic hypersensitivity 3. Type III immune complex-mediated hypersensitivity 4. Type IV delayed hypersensitivity Answer: 1 Explanation: 1. Common hypersensitivity reactions, such as allergic asthma, allergic rhinitis, allergic conjunctivitis, hives, and anaphylactic shock, are typical of type I or IgE-mediated hypersensitivity. This type of hypersensitivity response is triggered when an allergen interacts with IgE bound to mast cells and basophils. The antigen-antibody complex prompts the release of histamine and other chemical mediators, complement, acetylcholine, kinins, and chemotactic factors When a potent allergen such as bee or wasp venom or a drug is injected, resulting in widespread antibody-antigen reaction and response to these chemical mediators, a systemic response such as anaphylaxis, urticaria, or angioedema occurs. 2. A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. 3. Type III hypersensitivity reactions result from the formation of IgG or IgM antibody-antigen immune complexes in the circulation, leading to tissue damage. 4. Type IV delayed hypersensitivity reactions result from an exaggerated interaction between an antigen and normal cell-mediated mechanisms. Page Ref: 366 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

5 ..

6) A patient is diagnosed with a type IV delayed hypersensitivity reaction. For which reason did this type of reaction occur? 1. Latex allergy 2. Reaction to a wasp sting 3. Serum sickness 4. Autoimmune hemolytic anemia Answer: 1 Explanation: 1. Contact dermatitis is a classic example of a type IV reaction. In the healthcare setting, an allergic response to latex can produce contact dermatitis. 2. A reaction to a wasp sting is an example of a type I reaction. 3. Serum sickness is an example of a type III reaction. 4. Autoimmune hemolytic anemia is an example of a type II reaction. Page Ref: 370 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

6 ..

7) A patient develops hemolytic anemia after receiving a dose of penicillin. What action should the nurse realize is indicated for this patient? 1. Administer no further doses of penicillin. 2. Administer a blood transfusion. 3. Provide oxygen. 4. Increase fluids. Answer: 1 Explanation: 1. Type II reactions may be stimulated by a drug reaction, in which the drug forms an antigenic complex on the surface of a blood cell, stimulating the production of antibodies. The affected cell is then destroyed in the resulting antigen-antibody reaction. Hemolytic anemia is sometimes associated with the administration of drugs such as penicillin. Withdrawal of the drug stops the reaction and cell destruction. 2. A blood transfusion will not stop the reaction. 3. Oxygen will not stop the reaction. 4. Fluids will not stop the reaction. Page Ref: 368 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

7 ..

8) A patient develops a fever, rash, joint and muscle pain, and swollen lymph nodes after receiving a sulfonamide. What should these symptoms suggest to the nurse? 1. Serum sickness 2. Exacerbation of a disease process 3. Acute influenza 4. Subacute rheumatoid arthritis Answer: 1 Explanation: 1. Manifestations of serum sickness include fever, urticaria or rash, arthralgias, myalgias, and lymphadenopathy. Serum sickness can occur in response to some drugs, such as penicillin and sulfonamides. 2. The patient is not experiencing an exacerbation of a disease process. 3. The patient is not experiencing acute influenza. 4. The patient is not experiencing subacute rheumatoid arthritis. Page Ref: 269 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

8 ..

9) A patient recovering from a bone marrow transplant develops a maculopapular rash on the palms of both hands and the soles of the feet along with severe abdominal pain and bloody diarrhea. What should the nurse suspect this patient is experiencing? 1. Graft-versus-host disease 2. Chronic tissue rejection 3. Acute tissue rejection 4. Hyperacute tissue rejection Answer: 1 Explanation: 1. In a transplant patient, a maculopapular pruritic rash beginning on the palms of the hands and soles of the feet indicates graft-versus-host disease. The rash can spread to involve the entire body and lead to desquamation. Gastrointestinal manifestations include abdominal pain, nausea, and bloody diarrhea. 2. Chronic tissue rejection occurs from 4 months to years after the transplant of new tissue. 3. Acute tissue rejection is the most common type of rejection, and occurs between 4 days and 3 months after the transplant. Acute rejection is mediated primarily by the cellular immune response, resulting in transplant cell destruction. The patient experiencing rejection demonstrates manifestations of the inflammatory process, with fever, redness, swelling, elevated BUN, creatinine, lower enzymes, and elevated bilirubin and cardiac enzymes. 4. Hyperacute tissue rejection leads to rapid deterioration of organ function. Page Ref: 379 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

9 ..

10) A patient is diagnosed with valvular heart disease after experiencing rheumatic heart fever. What should the nurse realize caused this disorder? 1. Molecular mimicry 2. Release of hidden antigens into the circulation 3. Biologic changes that cause self-antigens to produce autoantibodies 4. Autoimmune response by slow-growing mycobacteria Answer: 1 Explanation: 1. The introduction of an antigen whose properties closely resemble those of host tissue results in the production of antibodies that target not only the foreign antigen but also normal tissue. This is considered molecular mimicry. Heart damage in rheumatic fever is an example of the development of antibodies against normal tissue. 2. This is not the release of hidden antigens into the circulation. 3. This is not biologic changes that cause self-antigens to produce autoantibodies. 4. This is not an autoimmune response due to slow-growing mycobacteria. Page Ref: 374 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

10 ..

11) A patient is concerned about developing rheumatoid arthritis because a family member has so much pain from the disorder. What should the nurse respond? 1. "Autoimmune disorders are genetically linked." 2. "The only way you will develop this disorder is if you become highly stressed." 3. "The amount of estrogen you have in your body will prevent the onset of the disorder." 4. "Limit your physical activity to prevent the onset of the disorder." Answer: 1 Explanation: 1. It is apparent that genetics play a role in autoimmune disorders because a higher incidence is seen in family members of people with these disorders. More than one genetic change is likely occurring to cause development of autoimmune disorders. 2. Stress is not the only cause of the disorder. 3. There is no information linking estrogen to the development of an autoimmune disorder. 4. Limiting physical activity will not prevent the onset of the disorder. Page Ref: 375 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

11 ..

12) A patient had skin taken from the upper thigh and placed over a burn area on the shoulder. Which should be the likely outcome from this procedure? 1. The graft will be successful. 2. The graft will immediately become cyanotic. 3. The graft will become swollen and edematous within 3 to 4 months. 4. The graft will lift away from the body over several years. Answer: 1 Explanation: 1. An autograft, a transplant of the patient's own tissue, is the most successful type of tissue transplant. A skin graft is an example of an autograft. 2. Evidence of immediate cyanosis describes hyperacute tissue rejection. 3. Acute tissue rejection occurs within 3 to 4 months and is not typically seen with a skin graft. 4. Chronic tissue rejection occurs from 4 months to years after the transplant and is not typically seen with a skin graft. Page Ref: 377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

12 ..

13) A patient is prescribed an immunosuppressive agent. Which patient statement indicates that additional teaching about this medication is required? 1. "I should drink a lot of fruit juices, such as grapefruit juice." 2. "I know to call the physician if I start experiencing a lot of bruising." 3. "I should drink plenty of water to keep from getting dehydrated." 4. "If I experience any joint pain, I should take ibuprofen for the pain as needed every 4 hours." Answer: 1 Explanation: 1. Immunosuppressive agents inhibit T cell development and activation. They are given concurrently with glucocorticoids and in combination with other immunosuppressants, and inhibit immune system activity and organ rejection. Nursing responsibilities include monitoring blood urea nitrogen levels and creatinine for evidence of nephrotoxicity. The patient should avoid grapefruit juice, which can raise cyclosporine levels by 50% to 200% and increase the risk of toxicity. 2. The physician should be notified about any bruising. 3. Fluids should be increased to maintain good hydration and urinary output. 4. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents. Page Ref: 381 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

13 ..

14) A patient who is immunosuppressed asks why so many illnesses are occurring. How should the nurse respond? 1. "You are unable to develop immunity to common bacteria, so you experience more illnesses." 2. "Your body takes longer to develop an immune response." 3. "Your body thinks everything is foreign matter and responds with an illness." 4. "You are under severe stress, which is causing the illnesses." Answer: 1 Explanation: 1. Patients with immunodeficiency disorders demonstrate an unusual susceptibility to infection. When the antibody-mediated response is primarily affected, the patient is at particular risk for severe and chronic bacterial infections. Patients with a defect of cell-mediated immunity tend to develop disseminated viral infections such as herpes simplex and cytomegalovirus. Overwhelming bacterial infections may occur. Patients with combined immunodeficiency are susceptible to all varieties of infectious organisms, including those not normally considered pathogens. 2. The patient's body does not take longer to develop an immune response. 3. The patient's body does not think everything is foreign matter. 4. Severe stress is not causing the illnesses. Page Ref: 385 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

14 ..

15) A patient is suspected of having a hypersensitivity reaction. Which laboratory test result supports this suspicion? 1. Patch test with a 1-inch area of erythema 2. Eosinophils 2% of the total WBC 3. Coombs indirect showing no agglutination 4. Elevated hematocrit level Answer: 1 Explanation: 1. A patch test assesses a 1-inch area impregnated with the allergen and is applied for 48 hours. Absence of a response indicates a negative result. Positive responses are graded from mild erythema in the exposed area to severe papules, vesicles, or ulcerations. 2. The normal range of the eosinophil count is 1%-4%. 3. The Coombs indirect test checks the recipient's and donor's blood for antibodies before a blood transfusion. 4. There is not enough information about the elevated hematocrit level. Page Ref: 271 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

15 ..

16) A patient has a history of severe responses to skin testing done for allergies. What should be used in place of skin testing for this patient? 1. Radioallergosorbent test 2. White blood cell count and differential 3. Blood type and crossmatch 4. Immune complex assay Answer: 1 Explanation: 1. The radioallergosorbent test (RAST) is a blood test that measures the amount of IgE directed toward specific allergens. Test results are compared with control values and used to identify hypersensitivities. This test may also be used instead of skin testing if a severe allergic response is suspected. 2. White blood cell count and differential is not used instead of skin testing if a severe allergic response is suspected. 3. Blood type and crossmatch is not used instead of skin testing if a severe allergic response is suspected. 4. Immune complex assay is not used instead of skin testing if a severe allergic response is suspected. Page Ref: 371 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

16 ..

17) The intradermal skin test conducted on a patient is positive. What did the nurse most likely assess in this patient? 1. A wheal larger than 5 cm from the control and erythema 2. Localized, itchy wheal 3. Papules 4. Ulceration Answer: 1 Explanation: 1. The appearance of a wheal and erythema, with a wheal diameter at least 5 mm larger than that produced by the control, indicates a positive response in an intradermal skin test. 2. A localized, itchy wheal would be a positive response for a prick test. 3. Papules would be a positive response for a patch test. 4. An ulceration would be a positive response for a patch test. Page Ref: 371 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

17 ..

18) After one week on an elimination diet to help identify food allergies, the patient's symptoms resolve. What should be planned for this patient? 1. Reintroducing the eliminated foods one at a time to determine the allergy. 2. Resuming the regular pre-elimination diet. 3. Taking an antihistamine before eating a food that causes a food allergy. 4. Consuming foods identified as causing allergies for the full week following the elimination diet. Answer: 1 Explanation: 1. If symptoms improve after an elimination diet, foods are reintroduced one at a time until symptoms recur, indicating allergy to that food. 2. The patient should not resume the pre-elimination diet. 3. The patient should not take an antihistamine prior to eating a food that has been identified as causing an allergy. 4. The patient should not consume foods known to cause an allergic response. Page Ref: 371 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

18 ..

19) A patient is experiencing symptoms of exposure to environmental ragweed. About which medication should the nurse instruct this patient? 1. Antihistamines 2. Antibiotics 3. Antiviral medications 4. Antifungal medications Answer: 1 Explanation: 1. Antihistamines alleviate the systemic effects of histamine such as urticaria and angioedema. They are also useful in relieving allergic rhinitis, drying respiratory secretions through an anticholinergic effect. The preferred route of administration is oral, and side effects include drowsiness and dry mouth. 2. The patient will not be prescribed an antibiotic. 3. The patient will not be prescribed an antiviral medication. 4. The patient will not be prescribed an antifungal medication. Page Ref: 372 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

19 ..

20) A patient diagnosed with rheumatoid arthritis is not responding to NSAID therapy. Which medication or therapy may be considered for this patient's treatment? Select all that apply. 1. Gold salt

2. Plasmapheresis 3. Methotrexate (Rheumatrex) 4. Infliximab (Remicade) 5. Corticosteroids Answer: 3, 4, 5 Explanation: 1. Gold salt is not an option to treat the patient with rheumatoid arthritis. 2. Plasmapheresis may or may not be indicated for this patient. 3. Methotrexate (Rheumatrex) may be used to inhibit immune responses in autoimmune disorders. 4. Infliximab (Remicade) reduces the inflammatory process in autoimmune disorders. 5. Corticosteroids may be prescribed to reduce the inflammatory response and minimize tissue damage. Page Ref: 375, 377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

20 ..

21) A patient receiving cyclosporine after an organ transplant is experiencing an acute onset of hypertension and headaches. What should these assessment findings suggest to the nurse? 1. These are signs of toxicity. 2. This is a normal reaction to the medication. 3. These are signs of impending transplanted organ failure. 4. The transplanted organ is beginning to function. Answer: 1 Explanation: 1. Cyclosporine is both nephrotoxic and hepatotoxic. Toxic effects include hypertension and CNS symptoms such as flushing or tingling of the extremities, confusion, visual disturbances, and seizures or coma. The nurse should report these assessment findings to the physician. 2. This is not a normal reaction to the medication. 3. These are not signs of impending organ failure. 4. These are not signs that the transplanted organ is beginning to function. Page Ref: 379 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

21 ..

22) A patient with AIDS experiences nausea, fever, severe diarrhea, and anorexia. Which medication would be the most effective to relieve the anorexia, as well as to stimulate the patient's appetite? 1. Megestrol (Megace) 2. Ciprofloxacin (Cipro) 3. Zidovudine (Retrovir, AZT) 4. Abacavir (Ziagen) Answer: 1 Explanation: 1. Megestrol (Megace) can be prescribed to increase the patient's appetite and promote weight gain. 2. Ciprofloxacin (Cipro) is an anti-infective medication. 3. Zidovudine (Retrovir, AZT) is an antiretroviral agent. 4. Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase. Page Ref: 397 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

22 ..

23) The nurse is instructing a patient with AIDS regarding foods that will increase caloric intake. Which meal choice indicates that the patient understands which types of foods to consume? 1. Spaghetti and meat sauce, raisin salad, whole grain roll with butter, vanilla milkshake (with Ensure), and a piece of pecan pie 2. Baked chicken (thigh), cabbage, small green salad, slice of white bread, dried prunes, and a soda 3. Red beans and rice, slaw, tomato, crackers, chocolate pudding, and iced tea 4. Vegetable soup, small piece of cornbread, banana pudding, and water Answer: 1 Explanation: 1. A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal would provide the most calories. 2. A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal would not provide the most calories. 3. A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal would not provide the most calories. 4. A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. This meal would not provide the most calories. Page Ref: 397 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

23 ..

24) A patient with HIV has an HIV viral load test of 9,000 copies/mL. What should this test result suggest to the nurse? 1. The current prescribed medication therapy is not effective. 2. The current prescribed medication therapy is effective. 3. The dose of prescribed medication can be reduced. 4. A less toxic medication needs to be prescribed. Answer: 1 Explanation: 1. HIV viral load tests measure the amount of actively replicating HIV. Levels correlate with disease progression and response to antiretroviral medications. Levels greater than 5,000 to 10,000 copies/mL indicate the need for treatment. 2. The patient's current prescribed medication is not effective. 3. The patient's medication dose should not be reduced. 4. This laboratory value does not indicate toxicity. Page Ref: 391 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

24 ..

25) The nurse is teaching a patient newly diagnosed with HIV. Which patient statement indicates the need for additional teaching? 1. "I know to use an oil-based lubricant to prevent giving the disease to my partner." 2. "I know I have to practice safe sex with my partner." 3. "I will not share my toothbrush or razor with my partner." 4. "I know I can't donate blood anymore because I have HIV." Answer: 1 Explanation: 1. The nurse should educate the patient on how to prevent the spread of HIV, including the need to use latex condoms with a spermicidal lubricant. 2. The patient is also correct about having to practice safe sex with a partner. 3. The patient is correct in stating that it is not an acceptable practice to share toothbrushes or razors. 4. The patient is also correct in stating that blood donation is prohibited. Page Ref: 398 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

25 ..

26) A patient is demonstrating signs of anaphylactic shock. What should the nurse do first to assist this patient? 1. Administer subcutaneous epinephrine. 2. Maintain an airway. 3. Provide calm reassurance. 4. Place the patient on a cardiac monitor. Answer: 2 Explanation: 1. Epinephrine may be administered after another step is performed. 2. Establishing and maintaining a patent airway is of primary importance when a patient demonstrates anaphylactic shock. 3. The patient can be reassured after the other interventions have been performed. 4. A cardiac monitor may be connected after another step is performed. Page Ref: 373 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

26 ..

27) A patient says, "I had this arthritis pain under control, but then I learned I might lose my job." How should the nurse respond? 1. "Well, we'd better do everything to help you before you lose your health benefits." 2. "I'm sure you'll find another job." 3. "Stress can exacerbate arthritis." 4. "Have you considered going on disability?" Answer: 3 Explanation: 1. The nurse should not compound the patient's anxiety by appearing to assume the patient will lose health benefits. 2. The nurse should not compound the patient's anxiety by appearing to assume the patient will lose the job. 3. The onset of an autoimmune disorder is frequently associated with an abnormal stressor, either physical or psychological. Autoimmune disorders are frequently progressive relapsingremission disorders characterized by periods of exacerbation and remission. 4. Arthritis is a condition associated with periods of remission and exacerbation. The patient should be encouraged to remain as active as possible and avoid giving up. Page Ref: 375 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Stress Management Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

27 ..

28) A patient with an autoimmune disorder says, "My family keeps telling me I don't look sick." Which problem should the nurse use to guide this patient's care? 1. Lack of family comprehension about the disease process 2. Alteration in body functions 3. Inability of the patient to cope with the health problem 4. Inability of the patient to tolerate activity Answer: 1 Explanation: 1. This patient states that the family does not recognize a disease process based on the patient's physical appearance. This suggests that the family does not comprehend the disease process. 2. There is no evidence that the patient is experiencing an alteration in body functions. 3. There is no evidence that the patient is unable to cope with the health problem. 4. There is no evidence that the patient is unable to tolerate activity. Page Ref: 377 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

28 ..

29) A patient is prescribed a monoclonal antibody after an allograft on the left thigh. What does the use of this medication suggest to the nurse? 1. The patient will have a shorter recovery time. 2. This medication has fewer adverse effects. 3. There is a risk for steroid-resistant rejection of the graft. 4. The patient is at risk for developing a graft infection. Answer: 3 Explanation: 1. The use of this medication does not indicate that the patient will have a shorter recovery time. 2. There is no evidence that this medication has fewer adverse effects. 3. Because of significant side effects, the use of OKT3, a monoclonal antibody, is limited primarily to treatment of steroid-resistant rejection. 4. There is no evidence to suggest that the patient is at risk for developing a graft infection. Page Ref: 380 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

29 ..

30) A patient with HIV is complaining of increased pain in the feet and legs. What should the nurse realize this patient is demonstrating? 1. A reaction to the medication 2. An opportunistic infection 3. A secondary cancer 4. A nervous system manifestation of the disease Answer: 4 Explanation: 1. These symptoms do not indicate a reaction to the medication. 2. These symptoms do not indicate the development of an opportunistic infection. 3. These symptoms do not indicate the development of a secondary cancer. 4. Neurologic problems attributable to HIV include inflammatory, demyelinating, and degenerative changes. Page Ref: 389 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Neurologic problems attributable to HIV include inflammatory, demyelinating, and degenerative changes | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

30 ..

31) A young female patient with HIV does not want to see the gynecologist because "I'm going to die anyway." How should the nurse respond? 1. "Having a PAP smear will help detect the onset of cervical cancer." 2. "Why do you think you are going to die?" 3. "The gynecologist will help diagnose any Hodgkin disease." 4. "But you still should be on birth control." Answer: 1 Explanation: 1. Cervical cancer develops frequently in females with HIV infection and tends to be aggressive. Females with concurrent HIV infection and cervical cancer usually die of the cervical cancer, not AIDS. Because of this, it is recommended that females with HIV infection have Papanicolaou (Pap) smears every 6 months and aggressive treatment of cervical dysplasia with colposcopic examination and cone biopsy. 2. While the nurse should investigate the patient's feelings, the emphasis is on preventive treatments. 3. The gynecologist does not focus on the diagnosis of Hodgkin disease. 4. Safe sex practices and the use of contraceptives are within the scope of the gynecologist; however, this is not the primary focus of the interaction. Page Ref: 390 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

31 ..

32) A patient with HIV is not adhering to the prescribed medication therapy. Which nursing action will best improve patient compliance and the long-term treatment of the disease process? 1. Confront the patient about the noncompliant behavior. 2. Talk with the patient about not adhering to the medication schedule. 3. Suggest that the patient take the medication at bedtime to prevent nausea. 4. Refer the patient to a social worker so that lower-cost medications can be obtained. Answer: 2 Explanation: 1. Confronting the patient would lead to alienation. 2. Provider-patient relationships seem to have the most influence on adherence behavior. 3. There is nothing in the question to suggest that nausea is a side effect of the medication. 4. There is no reason to assume that the noncompliance is due to a financial reason. Page Ref: 392 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

32 ..

33) An adolescent patient asks the nurse about sexual practices that help avoid contracting HIV. What should the nurse instruct this patient? 1. Always use a condom. 2. Be sure to be tested for HIV every 6 months. 3. There is no such thing as safe sex. 4. The only safe sex is no sex. Answer: 4 Explanation: 1. Condoms have risks associated with their use during sexual activity. 2. Testing for HIV every 6 months is unrealistic and will not prevent contracting the virus. 3. Sex can be safe. 4. Safe sex practices include no sex, long-term mutually monogamous sexual relations between two uninfected people, and mutual masturbation without direct contact. Page Ref: 399 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

33 ..

34) The nurse is preparing to instruct a class of young adults about ways to perform safe sex. What should be included in the nurse's presentation? Select all that apply. 1. Avoid spermicidal agents. 2. Get tested for HIV if entering into a new monogamous relationship. 3. Use oral birth control pills. 4. Use only oil-based lubricants with condoms. 5. Avoid sharing intravenous drug paraphernalia. Answer: 2, 5 Explanation: 1. For vaginal or anal sex, the condom should be lubricated with the spermicidal agent nonoxynol-9 for additional protection. 2. Sex should be practiced only after learning the partner's HIV status. 3. Oral birth control pills do not reduce the transmission of HIV. 4. Using an oil-based lubricant such as petroleum jelly can result in condom damage; waterbased lubricants are acceptable. 5. People who use intravenous drugs should never share needles, syringes, or other drug paraphernalia. Page Ref: 399 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

34 ..

35) A patient is diagnosed with a type I hypersensitivity reaction. Which chemical mediators should the nurse realize caused the patient's symptoms? Select all that apply. 1. Histamine 2. Complement 3. Autoantibodies 4. Erythrocytes 5. Kinins Answer: 1, 2, 5 Explanation: 1. Histamine is a chemical mediator released by the mast cells in a Type I hypersensitivity reaction. 2. Complement is a chemical mediator released by the mast cells in a Type I hypersensitivity reaction. 3. Autoantibodies are not released by the mast cells in a Type I hypersensitivity reaction. 4. Erythrocytes are not released by the mast cells in a Type I hypersensitivity reaction. 5. Kinins are chemical mediators released by the mast cells in a Type I hypersensitivity reaction. Page Ref: 366 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

35 ..

36) The nurse is preparing to instruct a patient with hypersensitivity reactions to bee stings. What should the nurse include in this teaching? Select all that apply. 1. Wear a medical-alert bracelet identifying the allergy at all times. 2. Carry a bee sting kit at all times. 3. Wear long-sleeved clothing while outdoors. 4. Minimize exposure by staying indoors. 5. Take an antihistamine prior to going outdoors. Answer: 1, 2 Explanation: 1. This patient should wear a Medic-alert bracelet identifying the patient's allergy at all times. 2. This patient should carry an epinephrine pen at all times. 3. Specific clothing is not recommended. 4. It is not necessary for the patient to stay indoors. 5. It is not necessary to take an antihistamine prior to going outside. Page Ref: 374 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

36 ..

37) The nurse is preparing to assess patients in the clinic who are HIV positive. Which patient should the nurse realize is at the greatest risk for developing AIDS-associated secondary cancers? Select all that apply. 1. Men who have sex with men 2. Heterosexual couples who are monogamous 3. Females with cervical dysplasia 4. HIV-positive patients with Mycobacterium avium complex 5. HIV patients who have recently seroconverted Answer: 1, 3 Explanation: 1. HIV-positive men who have sex with men have an increased risk of developing AIDS-associated secondary cancers. 2. HIV-positive monogamous heterosexual couples do not have an increased risk of developing AIDS-associated secondary cancers. 3. HIV-positive females with cervical dysplasia have an increased risk of developing AIDSassociated secondary cancers. 4. HIV-positive patients with Mycobacterium avium complex do not have an increased risk of developing AIDS-associated secondary cancers. 5. HIV patients who have recently seroconverted do not have an increased risk of developing AIDS-associated secondary cancers. Page Ref: 390 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

37 ..

38) The nurse is planning care for an older patient. Which factor does the nurse realize affects this patient's immune status? Select all that apply. 1. Environmental pollution 2. A chronic illness 3. Presence of autoantibodies 4. Nutritional status 5. Quality of sleep and rest Answer: 1, 2, 3, 4 Explanation: 1. Environmental pollution affects the older person's immune status. 2. Chronic diseases affect the older person's immune status. 3. Autoantibodies affect the older person's immune status. 4. Nutritional status affects the older person's immune status. 5. Quality of rest and sleep are not identified as affecting the older person's immune status. Page Ref: 365 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1 Review the normal immune system function, including selfrecognition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

38 ..

39) The nurse is conducting a physical assessment on a patient experiencing a hypersensitivity reaction. On which area should the nurse focus this assessment? Select all that apply. 1. Skin condition 2. Mucous membranes 3. Peripheral pulses 4. Lymph nodes 5. Cranial nerve function Answer: 1, 2, 4 Explanation: 1. For the patient with a hypersensitivity reaction, the physical assessment should focus on the skin for lesions or rashes. 2. For the patient with a hypersensitivity reaction, the physical assessment should focus on mucous membranes of nose and mouth. 3. Peripheral pulses are not specific to immune function. 4. The cervical, axilla, and groin lymph nodes should be assessed for evidence of lymphadenopathy (swelling) or tenderness. 5. Cranial nerve function is not specific to immune function. Page Ref: 366 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.1 Review the normal immune system function, including selfrecognition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with altered immunity.

39 ..

40) A patient is being treated for an acute hypersensitivity reaction. Which assessment finding indicates that the patient is developing an alteration in cardiac output? Select all that apply. 1. Lethargy 2. Itchy skin 3. Urine output 15 mL/hr 4. Prolonged capillary refill 5. Blood pressure 98/50 mmHg Answer: 1, 3, 4, 5 Explanation: 1. A change in level of consciousness (lethargy, apprehension, or agitation) is often the first indicator of decreased cardiac output. 2. Pruritus is not an indication of an alteration in cardiac output. 3. As cardiac output drops, the glomerular filtration rate (GFR) falls. With an output of less than 30 mL/hr, the patient is at risk for acute kidney injury from ischemia. 4. As cardiac output falls, peripheral vessels constrict and tissue perfusion is impaired. 5. A fall in blood pressure may indicate shock. Page Ref: 373 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.2 Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

40 ..

41) A patient has a rheumatoid factor titer of 1:30. Which health problem might the patient be experiencing? Select all that apply. 1. Leukemia 2. Renal disease 3. Liver cirrhosis 4. Rheumatoid arthritis 5. Systemic lupus erythematosus Answer: 1, 2, 3 Explanation: 1. A rheumatoid factor titer between 1:20 and 1:80 may be present in leukemia. 2. A rheumatoid factor titer between 1:20 and 1:80 may be present in renal disease. 3. A rheumatoid factor titer between 1:20 and 1:80 may be present in liver cirrhosis. 4. A rheumatoid factor titer of 1:80 or higher indicates rheumatoid arthritis. 5. A rheumatoid factor is not diagnostic for systemic lupus erythematosus. Page Ref: 375 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with altered immunity.

41 ..

42) A patient is prescribed to receive lymphocyte immune globulin (Atgam) to prevent an immediate transplant reaction. What action should the nurse take when administering this medication? Select all that apply. 1. Measure hourly urine output. 2. Keep epinephrine at the bedside. 3. Premedicate with acetaminophen. 4. Plan to infuse the medication over 2 hours. 5. Measure vital signs every hour during the infusion. Answer: 2, 3, 5 Explanation: 1. The nurse should monitor for serum sickness by analyzing renal function studies. Hourly urine output measurements are not necessary. 2. Because of the risk for anaphylactic reactions, epinephrine should be kept at the bedside. 3. Acetaminophen is used to premedicate the patient prior to receiving this medication. 4. The medication is to be infused through a central line over 4 to 6 hours. 5. Vital signs are to be measured every hour while the medication is infusing. Page Ref: 382 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 13.3 Describe the pathophysiology and manifestations of autoimmune disorders and tissue transplant rejection, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with altered immunity.

42 ..

43) A patient with HIV is being treated with the protease inhibitor raltegravir (Ritonavir). Which effect should the nurse expect the patient to experience while taking this medication? Select all that apply. 1. Abdominal obesity 2. Reduction in viral load 3. Skeletal muscle wasting 4. Minimal adverse effects 5. Improved serum lipid levels Answer: 2, 4, 5 Explanation: 1. Abdominal obesity is not associated with raltegravir (Ritonavir). 2. Raltegravir (Ritonavir) is effective in reducing viral load. 3. Skeletal muscle wasting is not associated with raltegravir (Ritonavir). 4. Raltegravir (Ritonavir) is usually well tolerated by patients. 5. Raltegravir (Ritonavir) has a beneficial effect on lipids. Page Ref: 393 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

43 ..

44) A patient who engages in high-risk sexual behavior is urged to have total knee replacement surgery. What action should the patient consider prior to scheduling this surgery? Select all that apply. 1. Delay the surgery for 1 year. 2. Schedule the surgery immediately. 3. Begin medication therapy for HIV. 4. Have testing for HIV in 6 months. 5. Consider autologous transfusions for the surgery. Answer: 1 Explanation: 1. Patients in the window period between contraction of the virus and the development of detectable antibodies are able to transmit the virus to others, even though they do not yet test positive for HIV. This window period usually lasts from 6 weeks to 6 months. Rarely does it take 1 year to determine if a patient is HIV positive. 2. The surgery should not be scheduled until the patient's HIV status is determined. 3. There is no evidence to support the implementation of HIV medication therapy. 4. Patients in the window period between contraction of the virus and the development of detectable antibodies are able to transmit the virus to others, even though they do not yet test positive for HIV. This window period usually lasts from 6 weeks to 6 months. The patient should be tested in 6 months. 5. Patients in the window period between contraction of the virus and the development of detectable antibodies are able to transmit the virus to others. When possible, patients should be encouraged to use autologous transfusion, donating their own blood prior to an anticipated surgery. Page Ref: 400 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 13.4 Describe the pathophysiology and manifestations of disorders of impaired immune response, and outline the interprofessional care, nursing care, and transitions of care for patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with altered immunity.

44 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 14 Nursing Care of Patients with Cancer 1) A patient develops a new sore on the forearm that has been increasing in size and will not heal. Which sign indicates that this sore could be a malignant neoplasm? 1. Noncohesive, invasive, and invades and destroys surrounding tissues 2. Rapid growth, well-defined borders, and cohesiveness 3. Invasive, local, and does not stop at tissue border 4. Slow growth, well-defined borders, and encapsulated Answer: 1 Explanation: 1. Malignant neoplasms are invasive, are noncohesive, do not stop at the tissue border, invade and destroy surrounding tissues, are characterized by rapid growth, metastasize to distant sites, are not always easy to remove, and can recur. 2. Benign neoplasms are local, cohesive, with well-defined borders. They push other tissues out of the way, are characterized by slow growth, are encapsulated, are easily removed, and do not recur. 3. Benign neoplasms are local, cohesive, with well-defined borders. They push other tissues out of the way, are characterized by slow growth, are encapsulated, are easily removed, and do not recur. 4. Benign neoplasms are local, cohesive, with well-defined borders. They push other tissues out of the way, are characterized by slow growth, are encapsulated, are easily removed, and do not recur. Page Ref: 414 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

1 ..

2) After learning of having a benign tumor in the abdomen, the patient is overheard telling a family member about having cancer. What should the nurse say to the patient? 1. "There is a growth in the abdomen but it is encapsulated and after being removed, will not recur." 2. "This type of cancer is easily treated." 3. "This type of cancer will not spread to other tissues." 4. "Even though this growth has invaded other tissues, it can be contained." Answer: 1 Explanation: 1. A benign tumor is encapsulated, slow-growing, and once removed, will not recur. 2. The patient does not have cancer but rather a benign tumor. 3. Even though benign tumors will not spread to other tissues, the nurse should not refer to the growth as being cancer. 4. The growth has not invaded other tissues. Page Ref: 414 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

2 ..

3) A patient reports having a benign tumor that has spread into the lymph glands. How should the nurse respond to this patient? 1. "What did your doctor tell you about the tumor?" 2. "Benign tumors do not spread." 3. "That's a good thing that the tumor is benign." 4. "Since it is benign, are you going to have surgery to remove it?" Answer: 1 Explanation: 1. The patient believes that the tumor is benign; however, benign tumors do not spread. These types of tumors are encapsulated and can be easily removed. Since the patient seems to have conflicting information, the nurse should assess the patient by asking what the physician explained about the tumor. 2. The nurse should not tell the patient that benign tumors do not spread. 3. The nurse should not reinforce the patient's belief that the tumor is benign. 4. The patient may or may not know if surgery is indicated to remove the tumor. Page Ref: 414 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

3 ..

4) A patient with a history of cancer is surprised to learn that new cancer has been diagnosed in another body part. What should the nurse realize this patient is experiencing? 1. Metastasis 2. Contact inhibition 3. Destructive force from a benign neoplasm 4. A solid mass Answer: 1 Explanation: 1. Malignant cells from the primary tumor may travel through the blood or lymph to invade other tissues and organs of the body and form a secondary tumor called a metastasis. Malignant neoplasms can recur after surgical removal of the primary and secondary tumors and after other treatments. 2. Contact inhibition is a characteristic of benign neoplasms. 3. A destructive force from a benign neoplasm is when the benign tumor impinges upon a body part, causing damage. 4. Benign tumors are usually solid masses. Page Ref: 414 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

4 ..

5) A patient asks the nurse how his cancer developed. Which statement should the nurse avoid in responding to this patient? 1. "The theory of cellular mutation suggests that carcinogens cause mutations in cellular RNA." 2. "Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics." 3. "The majority of people do not have an inherited form of cancer." 4. "Known carcinogens include viruses, drugs, hormones, and chemical and physical agents." Answer: 1 Explanation: 1. The theory of cellular mutation suggests that carcinogens cause mutations in cellular DNA, not RNA. 2. Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics. Inherited cancers can become inactive by deletion or mutation. 3. The majority of people do not have an inherited form of cancer is a true statement. 4. Known carcinogens include viruses, drugs, hormones, and chemical and physical agents. Page Ref: 412 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.2 Outline the process and theories of carcinogenesis, and list the known carcinogens. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

5 ..

6) A patient with a history of smoking is diagnosed with cancer. Which stage of the cellular mutation theory of cancer was impacted by smoking? 1. Promotion 2. Initiation 3. Progression 4. Replication Answer: 1 Explanation: 1. The theory of cellular mutation suggests that there are agents that cause mutations in cellular DNA that transforms cells into cancer cells. These agents are called carcinogens and it is believed that the carcinogenic process has three stages: initiation, promotion, and progression. Promotion may last for years and includes conditions, such as smoking or alcohol use, that act repeatedly on the already affected cells. 2. The initiation stage involves permanent damage in the cellular DNA as a result of exposure to a carcinogen that was not repaired or had a defective repair. 3. In the progression stage, further inherited changes acquired during the cell replication develop into a cancer. 4. Replication is not a stage in the mutation theory of cancer. Page Ref: 412 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.2 Outline the process and theories of carcinogenesis, and list the known carcinogens. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

6 ..

7) A female patient asks why a procedure to remove part of the cervix that was infected with a virus is required. What should the nurse explain to this patient? 1. Human papillomavirus can cause cervical cancer. 2. The medication to treat this virus is toxic to the body. 3. If left untreated, it could spread to the liver. 4. If left untreated, it could spread to the breast. Answer: 1 Explanation: 1. Human papillomavirus has been linked to the development of cervical cancer. The nurse should explain how this could occur and why the patient would benefit from having the procedure to remove the area of the cervix infected with the virus. 2. There is no medication available to treat the human papillomavirus. 3. Untreated human papillomavirus can cause melanoma, cervical, penile, and laryngeal cancer. 4. Untreated human papillomavirus can cause melanoma, cervical, penile, and laryngeal cancer. Page Ref: 410 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-KnowHow; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.1 Differentiate the nonmodifiable and modifiable risk factors for cancer. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

7 ..

8) A patient with a history of using recreational cocaine says being addicted to cocaine is better than being diagnosed with cancer. What should the nurse respond to this patient? 1. "Cocaine has been linked to the development of cancer." 2. "I guess if that's what you would prefer." 3. "People who use cocaine do have a lower risk of developing cancer." 4. "As long as the cocaine is pure and not mixed with toxic chemicals." Answer: 1 Explanation: 1. Some recreational drugs also are implicated as carcinogens. These include the immunosuppressant promoters of heroin and cocaine. Because of this, cocaine has been linked to the development of cancer, which is what the nurse should explain to the patient. 2. The nurse should not minimize the patient's comment by replying about preferences. 3. People who use cocaine do not have a lower risk of developing cancer. 4. There is no evidence that the purity of cocaine prevents the development of cancer. Page Ref: 413 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.2 Outline the process and theories of carcinogenesis, and list the known carcinogens. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

8 ..

9) A college student with the Epstein-Barr virus has a history of smoking and recreational cocaine use and works for a floor refinishing company part-time. Which factor increases this student's risk for developing cancer? Select all that apply. 1. Drug use 2. Occupation 3. Smoking 4. Viral infection 5. Age Answer: 1, 2, 3, 4 Explanation: 1. Some recreational drugs are also implicated as carcinogens. Immunosuppressant promoters include heroin and cocaine. 2. Examples of industrial and environmental carcinogens include polycyclic hydrocarbons, found in soot; benzopyrene, found in cigarette smoke; and arsenic, found in pesticides. Other industrial and environmental chemicals are considered promotional agents. These include wood and leather dust, polymer esters used in plastics and paints, carbon tetrachloride, asbestos, and phenol. 3. Benzopyrene found in cigarette smoke contributes to the development of cancer. 4. Several viruses have been associated with the development of cancer. These viruses include Epstein-Barr. 5. The patient's young age is not a risk factor for the development of cancer. Page Ref: 413 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.2 Outline the process and theories of carcinogenesis, and list the known carcinogens. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

9 ..

10) The nurse is preparing to provide care to a group of assigned patients. Which patient should the nurse realize is at the highest risk for developing cancer? 1. An African American man 2. A Native American woman 3. A Hispanic man 4. A Hispanic woman Answer: 1 Explanation: 1. African Americans have the highest mortality rate for all cancers and major cancers among all ethnic groups. 2. There is no evidence that Native American women are at a higher risk for developing cancer. 3. There is no evidence that Hispanic males are at a higher risk for developing cancer. 4. There is no evidence that Hispanic women are at a higher risk for developing cancer. Page Ref: 407 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1 Differentiate the nonmodifiable and modifiable risk factors for cancer. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

10 ..

11) The nurse is concerned that a patient is at increased risk for developing cancer. What did the nurse assess to come to this conclusion? 1. Age 51, spouse deceased, downsized from employment, history of back and leg pain 2. Age 52, plays tennis twice a week, no alcohol intake, occasionally smokes a cigarette 3. Age 45, premenopausal, not planning to use hormone replacement therapy 4. Age 50, employed as a computer technician, uses the fitness center five times a week Answer: 1 Explanation: 1. The patient who is 51 with a deceased spouse, downsized from employment, and has a history of back and leg pain is experiencing a great deal of stress. Stress resulting from severe and/or cumulative losses is also implicated in promoting cancer. These losses, which are common to older adults, include the death of a spouse or friends, loss of position and status in society, and a decline in physical abilities. These repeated stressors can damage the immune system and may lead to the development of cancer. 2. This patient has fewer risk factors than the 51-year-old patient. 3. This patient has fewer risk factors than the 51-year-old patient. 4. This patient has fewer risk factors than the 51-year-old patient. Page Ref: 409 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1 Differentiate the nonmodifiable and modifiable risk factors for cancer. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

11 ..

12) The nurse is explaining the characteristics of malignant cells to a group of patients. Which patient statement indicates a good understanding of the information? 1. "The work of malignant cells is simpler than that of normal cells." 2. "Malignant cells continue to perform cellular functions." 3. "Malignant cells can reverse into benign cells if treated promptly." 4. "Malignant cells rarely break away from the primary tissue site and travel to other locations." Answer: 1 Explanation: 1. Simplified metabolic activities are a characteristic of malignant cells. The work of malignant cells is simpler than that of normal cells. 2. Malignant cells do not perform typical cellular functions. 3. Rarely does a malignant neoplasm revert to a benign state. 4. Transplantability is another characteristic of malignant cells. Malignant cells often break away from the primary tissue site and travel to other locations in the body. Page Ref: 415 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

12 ..

13) A patient diagnosed with an 8 cm tumor in the ascending colon asks how the tumor grew so large without any major symptoms. How should the nurse respond to this patient? 1. "The pressure of the growing tumor caused the other tissue to reduce in size so the tumor could take over the space." 2. "The tumor cells bound to the tissue within the colon." 3. "The tumor cells are loosely held together so they can move about freely." 4. "The tumor cells secreted chemicals that stopped the body's normal mechanism to remove foreign tissue." Answer: 1 Explanation: 1. The nurse should respond with the explanation about pressure atrophy. The pressure of a growing tumor can cause atrophy and necrosis of adjacent tissues. The malignancy then moves into the vacated space. 2. The response that the tumor cells bound to the tissue within the colon explains how the tumor became established in the colon. 3. The response about tumor cells moving about freely explains metastasis. 4. The response that tumor cells secrete chemicals that stopped the body's normal phagocytic mechanism explains how the tumor was able to continue to grow. Page Ref: 415 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

13 ..

14) A patient is diagnosed with hyperplasia of lung tissue. Which should the nurse consider as being the first course of treatment for this patient? 1. Identification and removal of the irritant causing the hyperplasia 2. Antibiotic therapy 3. Chemotherapy 4. Radiation therapy Answer: 1 Explanation: 1. Hyperplasia is an increase in the number or density of normal cells and occurs in response to stress, increased metabolic demands, or elevated levels of hormones. Although hyperplasia often reverses after the irritating factor is eliminated, it can lead to malignancy under certain conditions. The first course of treatment is to identify and remove the irritant causing the hyperplasia. 2. Antibiotic therapy is not a treatment for hyperplasia. 3. It is not clear whether the patient will need chemotherapy in the future. 4. It is not clear whether the patient will need radiation therapy in the future. Page Ref: 411, 412 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.2 Outline the process and theories of carcinogenesis, and list the known carcinogens. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

14 ..

15) After a liver biopsy, a patient is diagnosed with anaplasia of liver cells. What would be indicated for this patient's care? 1. Monitoring for the development of cancer. 2. Chemotherapy for liver cancer. 3. Monitoring for the onset of diabetes mellitus. 4. Medication to reverse the anaplastic cells. Answer: 1 Explanation: 1. Anaplasia is the regression of a cell to an immature or undifferentiated cell type. Anaplastic cell division is no longer under DNA control. Anaplasia usually occurs when a damaging or transforming event takes place inside the dividing, still undifferentiated cell, leading to loss of useful function. Anaplasia may occur in response to overwhelmingly destructive conditions inside the cell or in surrounding tissue. Anaplasia is not reversible, but the degree of anaplasia determines the potential risk for cancer. The patient will most likely need careful monitoring to ensure the cells do not develop into cancer. 2. The patient does not have cancer and would not need chemotherapy at this time. 3. Anaplastic cells of the pancreas would increase this patient's chances of developing diabetes mellitus. 4. Anaplastic cells cannot be reversed. Page Ref: 412 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.2 Outline the process and theories of carcinogenesis, and list the known carcinogens. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

15 ..

16) The nurse is preparing to assess a patient who is newly diagnosed with cancer. What should the nurse include in this assessment? 1. Body image concerns 2. Increased leukocytes 3. Bone pain 4. Increased hunger Answer: 1 Explanation: 1. There are several physical and psychologic effects that occur in a patient diagnosed with cancer. One of these effects is body image concerns. 2. The patient's leukocytes are usually decreased, not increased. 3. Bone pain will depend upon the type of cancer. 4. A change in appetite can occur, although is it usually a loss of appetite. Page Ref: 419, 438 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.4 Outline the physiologic and psychologic effects of cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

16 ..

17) A patient with cancer is admitted with a weight loss of 25 lbs. over the last month with progressive anorexia. Which physiological effect of cancer should the nurse suspect the patient is experiencing? 1. Anorexia-cachexia syndrome 2. Paraneoplastic syndrome 3. Infection 4. Esophageal obstruction Answer: 1 Explanation: 1. The anorexia-cachexia syndrome is specific to cancer because of the effect of cancer cells on the host's metabolism. The neoplastic cells divert nutrition to their own use while causing changes that reduce the patient's appetite. Early in the disease, glucose metabolism is altered, causing an increase in serum glucose levels. The tumor also secretes substances that decrease appetite by altering taste and smell and producing early satiety. 2. Paraneoplastic syndromes are indirect effects of cancer. They may be early warning signs of cancer or indicate complications or return of a malignancy. 3. An infection caused by cancer does not lead to anorexia. 4. Esophageal obstruction is not a specific physiological effect of cancer. Page Ref: 417-418 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.4 Outline the physiologic and psychologic effects of cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

17 ..

18) A patient with cancer does not want to experience any more pain. What should the nurse do to help this patient? 1. Discuss pain management options. 2. Explain that every patient with cancer has pain. 3. Review ways to reduce pain without the use of medication. 4. Instruct on why pain will continue throughout treatment. Answer: 1 Explanation: 1. The pain associated with cancer is usually undertreated because of an inappropriate use of opioids and barriers related to the healthcare provider, patient, family, institution, and society. Communication and knowledge deficit are the major barriers to effective pain management. Because of this, the nurse should discuss pain management options with the patient. 2. Not every patient with cancer has pain. 3. Reviewing ways to reduce pain without the use of medication may or may not be appropriate for the patient. 4. The nurse has no way of knowing whether the patient's pain will continue throughout treatment. Page Ref: 436 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

18 ..

19) A patient receiving radiation treatments to shrink a tumor reports not needing as much pain medication as before. What would explain the reduction of pain for this patient? 1. The radiation treatments reduced the size of the tumor and pressure on adjacent tissues. 2. The tumor is secreting pain-control chemicals initiated by radiation. 3. The patient is getting used to having pain. 4. The patient's pain receptors have been affected by cancer. Answer: 1 Explanation: 1. Direct tumor involvement is the primary cause of the pain experienced by people with cancer. The pain from tumor involvement is believed to be mechanical, resulting from stretching of tissues and compression. Radiation treatments that are successfully shrinking a tumor would reduce the amount of tissue compression by the tumor and reduce the pain. 2. The tumor is not secreting pain-control chemicals initiated by radiation. 3. The patient is not getting used to having pain. 4. The patient's pain receptors have not been affected by cancer. Page Ref: 419, 432 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.4 Outline the physiologic and psychologic effects of cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

19 ..

20) A patient is having a procedure that involves cutting through the skin to diagnose a mass located in the left breast. For which type of biopsy should the nurse plan care for this patient? 1. Incisional 2. Fine-needle 3. Needle core 4. Excisional Answer: 1 Explanation: 1. An incisional biopsy is the removal of part of a larger tumor by cutting through the skin. 2. A fine-needle biopsy uses a very thin needle to aspirate a small amount of tissue from the tumors. 3. A needle core biopsy uses a slightly larger needle than that used for a fine-needle biopsy to extract a small amount of tissue from tumors that cannot be aspirated by fine-needle aspiration. 4. An excisional biopsy is the removal of an entire tumor through surgery. Page Ref: 425 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

20 ..

21) A patient with neck cancer is scheduled for a diagnostic test to determine the success of treatment. For what test should the nurse expect to prepare this patient? 1. Magnetic resonance imaging (MRI) 2. Computed tomography 3. X-ray imaging 4. Ultrasonography Answer: 1 Explanation: 1. MRI is the diagnostic tool of choice for both screening and follow-up of cranial and head and neck tumors. 2. Computed tomography is used in the screening for renal cell and most gastrointestinal tumors. 3. X-ray imaging is still the method of choice for lung cancer. 4. Ultrasonography is used to detect early prostate cancers and is used to guide needle biopsy. Ultrasound imaging is also used for detecting masses in the denser breast tissue of young women. Page Ref: 422 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

21 ..

22) A male patient's prostate-specific antigen level was 2 ng/mL; however, the patient was diagnosed with prostate cancer. What additional laboratory test was done to determine this diagnosis? 1. Acid phosphatase 2. Albumin 3. Bilirubin 4. Calcium Answer: 1 Explanation: 1. The acid phosphatase level will be elevated in prostate cancer. 2. The albumin level will be decreased in malnutrition and metastatic liver cancer. 3. Bilirubin will be elevated in liver and gallbladder cancer. 4. Calcium will be elevated in bone cancer and ectopic parathyroid hormone production. Page Ref: 423 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

22 ..

23) A patient's carcinoembryonic antigen level was initially 16 ng/mL but is currently 6 ng/mL. What does the nurse realize this decreased level indicates for the patient? 1. The patient's treatment for cancer is effective. 2. The patient's treatment for cancer is not effective. 3. The patient has a new site of cancer. 4. The patient's cancer has metastasized. Answer: 1 Explanation: 1. The normal carcinoembryonic antigen level for a nonsmoker is 2.5 ng/mL and 5.0 ng/mL for a smoker. Cancer is diagnosed with a level greater than 12 ng/mL. A decrease in the level is an indication that treatment for cancer is effective. 2. The value would increase if the treatment for cancer were not effective. 3. This laboratory test cannot determine new sites of cancer. 4. This laboratory test cannot help determine if the cancer has metastasized. Page Ref: 423 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

23 ..

24) The nurse is explaining the different types of chemotherapy to a patient recently diagnosed with cancer. Which statement would be incorrect for the nurse to tell the patient? 1. "Antitumor antibiotics disrupt RNA replication and DNA transcription." 2. "The main hormones used in cancer therapy are the corticosteroids, which are phasespecific." 3. "Mitotic inhibitors are drugs that act to prevent cell division during the M phase." 4. "Alkylating agents basically act on preformed nucleic acids by creating defects in tumor DNA." Answer: 1 Explanation: 1. Antitumor antibiotics disrupt DNA replication and RNA transcription, not the other way around. This is the statement that would be incorrect for the nurse to tell the patient. Hormones and hormone antagonists are one class of chemotherapeutic agents. 2. The main hormones used in cancer therapy are the corticosteroids, which are phase-specific. 3. Mitotic inhibitors are drugs that act to prevent cell division during the M phase. 4. Alkylating agents basically act on preformed nucleic acids by creating defects in tumor DNA. Page Ref: 427 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

24 ..

25) A patient will be receiving busulfan (Myleran) as treatment for leukemia. Which intervention should the nurse include in the plan of care for this patient? 1. Assess for infection. 2. Administer anti-emetic prior to chemotherapy. 3. Assess oral mucous membranes. 4. Check stool for occult blood. Answer: 1 Explanation: 1. Nursing interventions for a patient receiving busulfan (Myleran) include monitoring white blood cell counts, monitoring blood urea nitrogen level, maintaining adequate fluid intake, assessing for infection, and assessing lungs for coarse rales. 2. Administering an anti-emetic prior to chemotherapy is not indicated for busulfan (Myleran). 3. Assessing the oral mucosa is not indicated for busulfan (Myleran). 4. Monitoring the stool for occult blood is not indicated for busulfan (Myleran). Page Ref: 428 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

25 ..

26) A patient diagnosed with breast cancer is receiving 5-Fluorouracil (5-FU). What action should the nurse take to assess for adverse effects? 1. Test stool for occult blood. 2. Monitor ECG. 3. Assess lung sounds. 4. Encourage daily fluid intake of 2‒3 L. Answer: 1 Explanation: 1. Assessing for bleeding by checking stool for occult blood is recommended when receiving 5-Fluorouracil (5-FU). 2. Monitoring the ECG is recommended in patients receiving antitumor antibiotics. 3. Assessing lung sounds is recommended in patients receiving alkylating agents. 4. Encouraging a daily fluid intake of 2‒3 L is recommended also for patients receiving alkylating agents. Page Ref: 428 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

26 ..

27) A patient is receiving vincristine (Oncovin) for cancer treatment. Which assessment finding should indicate to the nurse that the patient is experiencing a toxic reaction? 1. Pain and motor weakness 2. Hypotension 3. Cardiac dysrhythmias 4. Stomatitis and alopecia Answer: 1 Explanation: 1. The toxicity of vincristine is characterized by depression of deep tendon reflexes, paresthesias, motor weakness, cranial nerve disruptions, and paralytic ileus. 2. Hypotension is not associated with a toxic reaction to vincristine. The worst common toxic side effect of etoposide is hypotension resulting from too rapid intravenous administration. 3. Cardiac dysrhythmias are not associated with a toxic reaction to vincristine. The main toxic effect of antitumor antibiotics is damage to the cardiac muscle. 4. Stomatitis and alopecia are not associated with a toxic reaction to vincristine. Toxic effects of antimetabolites include stomatitis and alopecia. Page Ref: 427 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

27 ..

28) The nurse is caring for a patient undergoing brachytherapy. What personal precaution should the nurse take when caring for this patient? 1. Wear a monitoring device to measure whole-body exposure. 2. Care for this patient regardless of pregnancy status. 3. Maintain the least possible distance from the patient. 4. Avoid indirect exposure with radioisotopes containers. Answer: 1 Explanation: 1. Many safety principles apply when caring for a patient receiving radiation. In brachytherapy, the radioactive material is placed directly into or adjacent to the tumor. The nurse should wear a monitoring device to measure whole-body exposure. 2. If the nurse is pregnant, it is advisable for her to avoid contact with radiation sources. 3. Maintain the greatest possible distance from the source of radiation. 4. Avoid direct, not indirect, exposure with radioisotopes containers; for example, do not touch the container. Page Ref: 433 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice-Know-How; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

28 ..

29) A patient is scheduled for a nephrectomy for renal cancer. What should the nurse recognize is the goal for this surgery? 1. Removal of the kidney 2. Removal of the organ 3. Bypass an obstruction 4. Decrease in tumor size Answer: 1 Explanation: 1. The decision to remove or resect an organ for cancer depends upon the organ and if there is some other means to replace the functioning of the lost organ. In the case of a nephrectomy, the patient's remaining kidney can maintain renal functioning. 2. Kidney function cannot be replaced chemically. 3. The removal of a kidney would not be done to bypass an obstruction. 4. The removal of a kidney would not be done to decrease the tumor's size. Page Ref: 425 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

29 ..

30) A patient is scheduled to receive a course of external radiation therapy for cancer treatment. What should the nurse instruct the patient about this therapy? 1. Wash the radiation site with mild soap. 2. Shave the treated area with a straight razor. 3. Apply ice packs to the treatment site to help reduce pain. 4. Use a sunscreen for three months after the conclusion of the treatments. Answer: 1 Explanation: 1. The nurse should instruct the patient to wash the skin that is marked as the radiation site only with mild soap. 2. The treated area should not be shaved. 3. Apply neither heat nor cold to the treatment site. 4. Cover skin with protective clothing during treatment; once radiation is discontinued, use sunblocking agents with a sun protection factor (SPF) of at least 15. Protect skin from sun exposure during treatment and for at least one year after radiation therapy is discontinued. Page Ref: 434 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

30 ..

31) A patient diagnosed with cancer and scheduled to begin biotherapy asks the nurse how the therapy will treat the cancer. How should the nurse respond to this patient? 1. "It changes the body processes that caused the cancer by enhancing your own immunity." 2. "It uses radiation implanted into the organ with the cancer." 3. "It uses laser therapy to remove the cancer." 4. "It uses stem cells to treat the cancer." Answer: 1 Explanation: 1. Biotherapy modifies the biologic processes that result in malignant cells, primarily through enhancing the person's own immune responses. This is what the nurse should explain to the patient. 2. Brachytherapy is the implantation of radiation into the organ with the cancer. 3. Photodynamic therapy uses medication that is activated by a laser to treat the cancer. 4. Peripheral blood stem cell transplantation is used to stimulate or replace nonfunctioning bone marrow. It does not treat cancer. Page Ref: 430 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

31 ..

32) A patient with a history of squamous cell lung cancer is admitted to the hospital with arm and periorbital edema. After a few hours, the patient exhibits dyspnea, cyanosis, tachypnea, and an altered level of consciousness. Which action should the nurse take first? 1. Administer oxygen. 2. Call the physician. 3. Monitor vital signs. 4. Initiate seizure precautions. Answer: 1 Explanation: 1. The superior vena cava can be compressed by mediastinal tumors or adjacent thoracic tumors. The most common cause is small-cell or squamous-cell lung cancers. Signs and symptoms can develop slowly, and include facial, periorbital, and arm edema as early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits can occur. Emergency measures include the following: provide respiratory support with oxygen, and prepare for a tracheostomy; monitor vital signs; administer corticosteroids to reduce edema; if the disorder is due to a clot, administer antifibrinolytic or anticoagulant drugs; provide a safe environment, including seizure precautions. 2. Contacting the physician is not the first priority. 3. Monitoring the patient's vital signs is important, but it is not the first action to take. 4. Seizure precautions would not be initiated first. Page Ref: 445 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

32 ..

33) The nurse suspects that a patient being treated for cancer is developing septic shock. What did the nurse assess to come to this conclusion? 1. High fever, peripheral edema, hypotension 2. Cardiac dysrhythmia, increased urine output, and confusion 3. Hypertension, increased urine output, and confusion 4. Subnormal temperature, cardiac dysrhythmia, and thirst Answer: 1 Explanation: 1. Sepsis occurs when bacteria gain entrance to the blood, grow rapidly, and produce septicemia. Signs and symptoms appear in two phases. The first phase includes vasodilation with hypovolemia, high fever, peripheral edema, hypotension, tachycardia, tachypnea, hot flushed skin with creeping mottling beginning in the lower extremities, and anxiety or restlessness. Without treatment, the shock progresses to the second phase, which includes hypotension; rapid, thready pulse; respiratory distress; cyanosis; subnormal temperature; cold, clammy skin; decreased urinary output; and altered mentation. 2. Confusion is associated with septic shock, but cardiac dysrhythmias and increased urine output are not. 3. Hypotension, not hypertension, and confusion are associated with septic shock. Increased urine output is not. 4. Subnormal temperatures can be associated with septic shock, but cardiac dysrhythmias and thirst are not. Page Ref: 445 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

33 ..

34) A patient with cancer is experiencing lower extremity numbness and loss of motor function. What should be done to assist this patient? 1. Assess for spinal cord compression. 2. Provide intravenous fluids. 3. Administer oxygen. 4. Turn and reposition every two hours. Answer: 1 Explanation: 1. Spinal cord compression is most commonly associated with pressure from expanding tumors of the breast, lung, or prostate; lymphoma; or metastatic disease. Spinal cord compression constitutes an emergency because of the potential for irreversible paraplegia. Back pain is the initial symptom in almost all cases of spinal cord compression. This may progress to leg pain, numbness, paresthesias, and coldness. Later, bowel and bladder dysfunction occur and, finally, neurologic dysfunction progressing from weakness to paralysis. Treatment often consists of radiation or surgical decompression, but early detection is essential. 2. Providing intravenous fluids is not the priority. 3. Providing oxygen is not the priority. 4. Turning and repositioning every two hours is not the priority. Page Ref: 446 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

34 ..

35) A patient diagnosed with prostate cancer is demonstrating signs of renal failure. What should this assessment finding suggest to the nurse? 1. Obstructive uropathy 2. Spinal cord compression 3. Urethral strictures from radiation 4. Bladder irritation from chemotherapy Answer: 1 Explanation: 1. Patients with prostate cancer may experience obstruction of the bladder neck or the ureters. Bladder neck obstruction usually manifests as urinary retention, flank pain, hematuria, or persistent urinary tract infections, but ureteral obstruction is not often evident until the patient is in renal failure. 2. Spinal cord compression does not cause renal failure. 3. Urethral strictures from radiation would not cause renal failure. 4. Bladder irritation from chemotherapy would not cause renal failure. Page Ref: 446 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

35 ..

36) The nurse is providing instructions to a patient diagnosed with renal cancer regarding when to call for help after discharge. Which statement by the patient indicates that teaching has been successful? 1. "I should call my physician if I experience new bleeding from any site." 2. "I should call my physician if I have an oral temperature higher than 100.5°F." 3. "I should call my physician if I have an episode of diarrhea." 4. "I should call my physician if I experience an occasional headache." Answer: 1 Explanation: 1. The nurse should instruct the patient to call the nurse or physician if any of the following signs or symptoms occur: oral temperature higher than 101.5°F; severe headache; significant increase in pain at usual site, especially if the pain is not relieved by the medication regimen, or severe pain at a new site; difficulty breathing; new bleeding from any site; confusion, irritability, or restlessness; verbalizations of deep sadness or a desire to end life; changes in eating patterns; changes in body functioning, such as severe diarrhea or constipation; withdrawal; frequent crying; greatly decreased activity level; and the appearance of edema in the extremities or significant increase in edema already present. 2. The patient should call the nurse or physician if an oral temperature is greater than 101.5°F, not 100.5°F. 3. The physician or nurse does not need to be contacted if the patient experiences an episode of diarrhea. 4. The physician or nurse does not need to be contacted if the patient experiences an occasional headache. Page Ref: 430 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

36 ..

37) A patient diagnosed with cancer contacted an attorney about a will and a church to arrange funeral and cemetery arrangements. What do this patient's activities suggest to the nurse? 1. The patient is participating in healthy grieving. 2. The patient feels he is going to die within the month. 3. The patient's family will not be willing to make funeral arrangements. 4. The patient wants something to do while waiting for chemotherapy treatments. Answer: 1 Explanation: 1. The patient with cancer is often confronted with facing death and making preparations for it. This can be a healthy response that allows the patient and family to work through the dying process and achieve growth in the final stage of life. 2. Participating in the activities of a will and funeral arrangements does not necessarily mean that the patient feels he is going to die within the month. 3. Participating in the activities of a will and funeral arrangements does not mean that the patient's family will not be willing to make funeral arrangements. 4. The patient is not doing these activities while waiting for chemotherapy treatments. Page Ref: 439-440 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

37 ..

38) The nurse is concerned that a patient receiving chemotherapy for cancer is at increased risk for developing an infection. What should the nurse include in this patient's plan of care? 1. Teach the patient to avoid crowds. 2. Encourage socialization with small children. 3. Contact physician with a temperature elevation. 4. Limit intake of protein and vitamin C. Answer: 1 Explanation: 1. The nurse should instruct the patient to avoid crowds and children to reduce the risk of developing an infection. 2. The nurse should instruct the patient to avoid socializing with children to reduce the risk of developing an infection. 3. Temperature elevation is a normal sign of an infection; however, severely immunocompromised patients may not be able to mount a fever. The absence of a fever does not rule out the presence of an infection. 4. The patient should be instructed to have an adequate daily intake of protein and vitamin C to support the body's immunity. Page Ref: 440 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others | AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring | NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

38 ..

39) The family of a patient with terminal metastatic cancer asks the nurse for guidelines regarding when to call for help when the patient is discharged to home. What guideline should the nurse instruct this family that indicates the patient needs medical intervention? Select all that apply. 1. Oral temperature greater than 100°F 2. Difficulty breathing 3. Onset of bleeding 4. Resting comfortably and reading 5. Extreme hunger Answer: 2, 3, 5 Explanation: 1. The patient should call the nurse or physician if the patient experiences an oral temperature greater than 101.5°F (38.6°C). 2. The patient should call the nurse or physician if the patient experiences difficulty breathing. 3. The patient should call the nurse or physician if the patient experiences a new onset of bleeding. 4. There is no reason to call the nurse or physician if the patient is resting comfortably and reading. 5. The patient should call the nurse or physician if the patient experiences extreme hunger. Page Ref: 430 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

39 ..

40) The nurse is caring for a patient diagnosed with a malignant neoplasm. What does the nurse recognize is a characteristic of this neoplasm? Select all that apply. 1. Localized encapsulated growths 2. Growths demonstrating contact inhibition 3. Irregularly shaped growths 4. Neoplasms that cause bleeding and inflammation 5. Growths that remain stable in size Answer: 3, 4 Explanation: 1. Benign neoplasms are localized growths. They form a solid mass, have welldefined borders, and frequently are encapsulated. 2. Benign neoplasms tend to respond to the body's homeostatic controls. Thus, they often stop growing when they reach the boundaries of another tissue (a process called contact inhibition). 3. In contrast to benign neoplasms, malignant neoplasms grow aggressively and do not respond to the body's homeostatic controls. Malignant neoplasms are not cohesive, and present with an irregular shape. 4. Instead of slowly crowding other tissues aside, malignant neoplasms cut through surrounding tissues, causing bleeding, inflammation, and necrosis (tissue death) as they grow. 5. They grow slowly and often remain stable in size. Page Ref: 414 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.3 Describe the types and characteristics of neoplasms and the process of tumor invasion and metastasis. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

40 ..

41) The nurse is reviewing the results of diagnostic testing on a patient suspected of having cancer. Which diagnostic finding should the nurse identify as being consistent with the presence of a malignancy? Select all that apply. 1. High levels of tumor markers 2. Positive biopsy results 3. Low levels of tumor markers 4. Decreased white blood cell count 5. Increased hemoglobin and hematocrit Answer: 1, 2 Explanation: 1. High levels of tumor markers are indicative of a malignancy. 2. Positive biopsy results are indicative of a malignancy. 3. High levels of tumor markers are indicative of a malignancy. 4. Leukopenia is not associated with a malignancy. 5. Increased hemoglobin and hematocrit values are not associated with a malignancy. Page Ref: 421, 425 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

41 ..

42) A patient is beginning radiation therapy as part of cancer treatment. What should the nurse teach the patient about the care of the radiation site? Select all that apply. 1. Clean radiation site with soap and water. 2. Apply lotion daily to prevent scaling. 3. Apply ice pack to radiation site if pain or itching occurs. 4. Use PABA-free sun-blocking agents with a sun protection factor (SPF) of at least 30. 5. Wear tight-fitting clothing over the area to protect it. Answer: 1, 4 Explanation: 1. The site may be cleaned with soap and water. 2. Lotion should not be applied to the site. 3. Ice packs should not be applied to the site. 4. Sun-blocking agents that are PABA-free with a sun protection factor (SPF) of at least 30 should be used. 5. Tight-fitting clothing should not be worn over the site. Page Ref: 434 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

42 ..

43) A patient with cancer is diagnosed with malnutrition. What does the nurse realize is a cause of malnutrition in this patient? Select all that apply. 1. Decreases in metabolism resulting from increased cancer cell production 2. Decreased available nutrients due to the cancer's parasitic activity 3. Loss of appetite due to side effects of chemotherapy 4. Decreased absorption in the gastrointestinal tract 5. Parenteral nutrition supplements administered via venous access devices Answer: 2, 3, 4 Explanation: 1. The patient's metabolism will increase, not decrease. 2. The patient with cancer may have a decreased amount of available nutrients. 3. Appetite may be lost because of the treatment. 4. The patient may not be able to absorb the nutrients well from the gastrointestinal tract. 5. Parenteral nutrition is not a cause of malnutrition. It can be used to help the patient with cancer. Page Ref: 440-441 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 3. Analyze assessment data to determine priorities of care for patients with cancer.

43 ..

44) The nurse realizes that a patient receiving chemotherapy for cancer is at risk for developing an infection. What action should the nurse take when caring for this patient? Select all that apply. 1. Monitoring red blood cell counts monthly 2. Teaching the patient to avoid small children 3. Teaching the patient to apply lotion daily to clean skin to prevent drying 4. Encouraging the patient to consume a diet high in protein and vitamin C 5. Teaching the patient to report an oral temperature above 98°F Answer: 2, 3, 4 Explanation: 1. Although RBCs are monitored, they do not diagnose infection as do WBCs. 2. Teach the patient to avoid crowds, small children, and people with infections when WBC count is at nadir (lowest point during chemotherapy) and to practice scrupulous personal hygiene. 3. Appropriate skin care measures, such as the use of a moisturizing lotion to prevent dryness and cracking ensures intact skin. 4. Improving nutrition decreases the risk of infection. Vitamin C has been shown to help prevent certain types of infection, such as colds. 5. A temperature of 98°F is normal and does not need to be reported to the nurse or physician. Page Ref: 440 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

44 ..

45) At the completion of a dietary history the nurse is concerned that a patient is at risk for developing cancer. Which food habit does the patient have that causes the nurse to have this concern? Select all that apply. 1. Eats red meat 5 times a week 2. Drinks 6 cups of coffee every day 3. Has a salad every evening with dinner 4. Prefers fried fish and chicken over baked 5. Orders a deli sandwich for lunch every day Answer: 1, 2, 4, 5 Explanation: 1. A diet that is high in red meat and saturated fat appears to increase the risk for cancer. 2. Both regular and decaffeinated coffee are believed to increase cancer risk. 3. Vegetables, fruits, fiber, folate, and calcium may be protective against cancer. 4. Repeatedly using fat to fry foods at high temperatures produces high levels of polycyclic hydrocarbons, which increase cancer risk considerably. 5. Some foods are considered genotoxic, such as the nitrosamines and nitrous indoles found in preserved meats and pickled, salted foods. Page Ref: 409 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.1 Differentiate the nonmodifiable and modifiable risk factors for cancer. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cancer.

45 ..

46) After cytologic examination a patient is diagnosed with a tumor that is staged as T IS, N1a, M0. What does this staging classification indicate to the nurse about the patient's tumor? Select all that apply. 1. TIS means the tumor is in situ. 2. M0 means that it has metastasized. 3. M0 means that it has not metastasized. 4. N1a means one lymph node is involved. 5. N1a means that no lymph nodes are involved. Answer: 1, 3, 5 Explanation: 1. TIS means that the tumor is in situ. 2. M0 means there is no evidence of distant metastasis. 3. M0 means there is no evidence of distant metastasis. 4. N1a means there is no metastasis to regional lymph nodes. 5. N1a means there is no metastasis to regional lymph nodes. Page Ref: 420 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

46 ..

47) A patient is to have chemotherapy provided to target the G1 phase of the cell cycle. Which medications should the nurse expect to be prescribed for this patient? Select all that apply. 1. Cisplatin 2. Prednisone 3. Methotrexate 4. Mercaptopurine 5. Nitrogen mustard Answer: 1, 2, 5 Explanation: 1. Cisplatin is a miscellaneous medication provided during the G1 phase of the cell cycle. 2. Prednisone is a hormone provided during the G1 phase of the cell cycle. 3. Methotrexate is an antimetabolite used during the S phase of the cell cycle. 4. Mercaptopurine is an antimetabolite used during the S phase of the cell cycle. 5. Nitrogen mustard is an alkylating agents prescribed during the G1 phase of the cell cycle. Page Ref: 426 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cancer.

47 ..

48) A patient is prescribed cyclophosphamide (Cytoxan) for treatment of lymphoma. What should the nurse instruct to maximize the health status of the patient while receiving this medication? Select all that apply. 1. Avoid eating spicy foods. 2. Discuss approaches to manage hair loss. 3. Identify approaches to reduce bone pain. 4. Brainstorm ways to manage constipation. 5. Ingest 2 to 3 L of fluid during treatment. Answer: 1, 2, 5 Explanation: 1. Adverse effects of cyclophosphamide (Cytoxan) include stomatitis. The patient should be instructed to avoid eating spicy foods. 2. Adverse effects of cyclophosphamide (Cytoxan) include alopecia. Approaches to managing hair loss should be discussed. 3. Bone pain is not an adverse effect of cyclophosphamide (Cytoxan). 4. Constipation is not an adverse effect of cyclophosphamide (Cytoxan). 5. Adverse effects of cyclophosphamide (Cytoxan) include hemorrhagic cystitis and renal failure. The nurse should instruct the patient to ingest 2 to 3 L of fluid during treatment. Page Ref: 428 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 14.5 Describe the interprofessional care, nursing care, and transitions of care for patients with cancer. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cancer.

48 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 15 Assessing the Integumentary System 1) A patient is experiencing a problem with the eccrine sweat glands. Which function should the nurse expect to be affected in this patient? 1. Regulation of body temperature 2. Regulation of body heat by excretion of perspiration 3. Sebum secretion 4. Sexual scent gland Answer: 2 Explanation: 1. The dermis regulates body temperature by dilating and constricting capillaries. 2. The eccrine sweat glands regulate body heat by excreting perspiration. 3. Sebaceous (oil) glands secrete sebum, which lubricates the skin and hair and plays a role in killing bacteria. 4. The apocrine sweat glands are a remnant of sexual scent glands. Page Ref: 445 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

1 ..

2) A patient reports avoiding the sun for fear of developing skin cancer. Which health problem is this patient at risk for developing? 1. Vitamin D deficiency 2. Hypercholesterolemia 3. Hypokalemia 4. Hypernatremia Answer: 1 Explanation: 1. The skin functions as a synthesizer of vitamin D (sunlight reacts with cholesterol). 2. Hypercholesterolemia results from factors such as dietary intake and cholesterol that is produced by the body. 3. The skin does prevent the loss of fluid and does play a role in fluid and electrolyte balance. However, avoiding the sun does not increase the patient's risk of developing hypokalemia. 4. The skin does prevent the loss of fluid and does play a role in fluid and electrolyte balance. However, avoiding the sun does not increase the patient's risk of developing hypernatremia. Page Ref: 465 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

2 ..

3) A patient who has experienced a burn involving both the epidermis and the dermis asks if the area will heal and appear as it was prior to the burn. What knowledge of skin structures should the nurse use to respond to this patient? Select all that apply. 1. Most hair follicles are in the dermis. 2. Most sweat glands are in the dermis. 3. Hair follicles are in the subcutaneous tissue. 4. Sebaceous glands are in the dermis. 5. Receptors for pain and touch are in the dermis. Answer: 1, 2, 4, 5 Explanation: 1. Most hair follicles are in the dermis. 2. Most sweat glands are in the dermis. 3. Hair follicles are not located in the subcutaneous tissue. 4. Most sebaceous glands are in the dermis. 5. The pain and touch receptors are in the dermis. Page Ref: 454 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

3 ..

4) The nurse is caring for an African American patient who has a serum bilirubin of 6 mg/100 mL. Which body area should be used as the best way to assess skin color changes in this patient? 1. Sclera 2. Palms of the hands 3. Fingernails 4. Skin of the inner arms Answer: 2 Explanation: 1. Sclera may be yellow near the limbus; however, this can be confused with normal yellow eye pigmentation. 2. In patients with dark skin, yellowing is best assessed at the junction of the hard palate and the soft palate, or on the palms of the hands. 3. Jaundice might be observed in the fingernails of a light-skinned patient. 4. Jaundice is not assessed by looking at the skin of the inner arms. Page Ref: 455 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

4 ..

5) An African American patient has an ashen cast to normally black skin. Which laboratory test results should the nurse review to determine a possible cause of the skin color change? 1. BUN and creatinine 2. Hemoglobin and hematocrit 3. Bilirubin and serum potassium 4. Oxygen saturation and red blood cell count Answer: 2 Explanation: 1. BUN and creatinine levels are associated with kidney function; uremia may manifest as a yellowish green color in the sclera of the eye. 2. Decreased hemoglobin and hematocrit indicate anemia, which presents in black skin as dullness and an ashen gray cast. 3. An elevated bilirubin level is seen as yellowing of the skin, especially evident in the palms of dark-skinned individuals. Serum potassium does not affect skin color. 4. Decreased oxygen saturation or low arterial blood gas levels present as cyanosis or a bluish discoloration in nail beds in dark-skinned individuals. The red blood cell count would be used to help determine a reason for a low oxygen saturation level because oxygen is carried on the red blood cell. Page Ref: 455 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.

5 ..

6) A Caucasian patient is admitted with possible carbon monoxide poisoning. Which skin color should the nurse expect to support this medical diagnosis? 1. Bluish 2. Dusky red 3. Cherry red 4. Orange green Answer: 3 Explanation: 1. Bluish skin is associated with cyanosis. 2. Dusky red skin is found in individuals with venous stasis. 3. Carbon monoxide poisoning is characterized by cherry red coloring of the face and upper torso. 4. Dusky red skin is found in individuals with venous stasis and orange green skin is found in individuals with uremia. Page Ref: 455 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

6 ..

7) While conducting a health history, the nurse learns that a patient worked at a steel mill for the last 35 years. Why should the nurse find this information significant? 1. Explains possible exposure to environmental toxins 2. Helps understand the patient's lack of communication skills 3. Validates that the patient is an older adult 4. Confirms the patient's level of education Answer: 1 Explanation: 1. The patient's occupation could involve exposure to such toxins as coal, tar, and/or petroleum products which increase the risk for developing skin cancer. 2. Working at a steel mill has no bearing on the patient's communication skills. 3. Working at a steel mill has nothing to do with the patient's age. 4. Working at a steel mill has no bearing on the patient's education level. Page Ref: 457 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

7 ..

8) A patient seeks medical attention for an erythematous generalized rash. Which question should the nurse ask about the rash? Select all that apply. 1. "Have you recently eaten any new foods?" 2. "What medications do you take?" 3. "Have you changed your soap?" 4. "Have you changed skin care lotions?" 5. "How often do you walk outside?" Answer: 1, 2, 3, 4 Explanation: 1. When assessing a patient with a new rash, precipitating factors such as dietary changes should be assessed. 2. When assessing a patient with a new rash, precipitating factors such as medications should be assessed. 3. When assessing a patient with a new rash, precipitating factors such as changes in soap should be assessed. 4. When assessing a patient with a new rash, precipitating factors such as changes in skin care lotion should be assessed. 5. Time spent out of doors will not help identify the cause of the rash. Page Ref: 456 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

8 ..

9) A patient asks what caused an elevated, darkened area of excess scar tissue to develop. In which way should the nurse respond? 1. "This scar was caused by the wearing away of the superficial epidermis, which left a moist, shallow depression." 2. "This scar was caused by excessive collagen formation during healing." 3. "This scar was caused by skin loss extending into the dermis or subcutaneous tissue." 4. "This scar was caused by wasting of the skin due to loss of collagen." Answer: 2 Explanation: 1. Erosion is the wearing away of the superficial epidermis, causing a moist, shallow depression. Because erosions do not extend into the dermis, they heal without scarring. 2. A keloid is an elevated, irregular area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. 3. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. 4. Atrophy is a translucent, dry-paper-like, sometimes wrinkled skin surface resulting from thinning or wasting of the skin due to loss of collagen and elastin. Page Ref: 459 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

9 ..

10) The nurse is performing an assessment of a patient's nails. What should be included in this examination? Select all that apply. 1. Thickness 2. Color 3. Curvature 4. Length 5. Grooves Answer: 1, 2, 3, 5 Explanation: 1. Nails should be inspected for thickness. 2. Nails should be inspected for color. 3. Nails should be inspected for curvature. 4. Nail length is not an important assessment. 5. Nails should be inspected for grooves. Page Ref: 462-463 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

10 ..

11) The nurse is providing care to patients in a community clinic. When should the nurse conduct a health assessment interview to determine problems with the integumentary system? Select all that apply. 1. When the patient has a complaint 2. As part of regular health screening 3. When completing a health assessment 4. Rarely, because it takes too much time 5. When the patient is over the age of 50 Answer: 1, 2, 3 Explanation: 1. A health assessment interview to determine problems with the integumentary system may focus on a chief complaint (such as itching or a rash). 2. A health assessment interview to determine problems with the integumentary system may be conducted as part of a health screening. 3. A health assessment interview to determine problems with the integumentary system may be conducted as part of a complete health assessment. 4. A health assessment interview to determine problems with the integumentary system is to be conducted regardless of the amount of time it takes to complete. 5. A health assessment interview to determine problems with the integumentary system is conducted on patients of all ages, not just those over the age of 50. Page Ref: 456 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

11 ..

12) A patient is diagnosed with oculocutaneous albinism. What does the nurse understand this health problem to be? 1. Hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin. 2. Disorder characterized by elevated scars and a familial tendency that is found more commonly in African Americans. 3. Sudden appearance of white patches on the skin, with a familial tendency. 4. Autosomal-dominant inheritance disorder that causes hyperpigmentation of the skin, hair, and eyes. Answer: 1 Explanation: 1. Oculocutaneous albinism is an autosomal-recessive disorder that causes hypopigmentation of the skin, hair, and eyes because of an inability to synthesize melanin. 2. Keloids are elevated scars, have a familial tendency, and are found more commonly in African Americans. 3. Vitiligo is the sudden appearance of white patches on the skin; it has a familial tendency. 4. Oculocutaneous albinism is an autosomal-recessive disorder that causes hypopigmentation of the skin, hair, and eyes. Page Ref: 457 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

12 ..

13) A female patient who is concerned about excessive hair on her arms and legs states that other female family members have the same problem. How should the nurse respond? 1. "The excessive hair growth could be a result of your diet." 2. "Your hair growth patterns may be inherited." 3. "Your excessive hair growth could be caused by too much sun." 4. "Maybe you shave too much, which causes more hair growth." Answer: 2 Explanation: 1. Diet is not known to increase arm and hair growth. 2. Hirsutism, or excessive hair growth, may be genetically predetermined. 3. Hirsutism is not caused by too much sun. 4. Hirsutism is not caused by excessive shaving. Page Ref: 457 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

13 ..

14) A patient complains of the sudden appearance of white patches on the skin. Which question should the nurse ask if vitiligo is suspected? Select all that apply. 1. "Have any of your parents or grandparents had this problem also?" 2. "Have you been using bleach lately?" 3. "Have you had anything rubbing on those areas excessively?" 4. "What have you been eating lately?" 5. "Where are the white patches located on your body?" Answer: 1, 5 Explanation: 1. Vitiligo has a familial tendency. 2. Vitiligo is not caused by chemical exposure. 3. Vitiligo is not caused by irritation. 4. Vitiligo is not caused by dietary factors. 5. Vitiligo usually occurs on the face, the hands, or the groin. Page Ref: 457, 461 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

14 ..

15) The nurse is completing an integumentary examination of an African American patient. Which finding should the nurse recognize is associated with the patient's genetics? Select all that apply. 1. An ashen hue to black skin 2. A yellowish cast on the palms 3. Very dry scalp and dry, fragile hair 4. Several keloids 5. Patches of white spots on the hands Answer: 3, 4, 5 Explanation: 1. An ashen hue to the skin is a sign of anemia. 2. A yellowish cast to the skin of the palms may indicate jaundice. 3. Dry scalp and dry, fragile hair may have a genetic origin in African American individuals. 4. Keloids occur in African American individuals with a familial tendency. 5. White patches, or vitiligo, often found over the skin of the face, hands, or groin, occur in individuals with a familial tendency. Page Ref: 457 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2 Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

15 ..

16) The nurse is caring for an older patient. What should the nurse keep in mind when caring for the patient's skin? 1. The subcutaneous layer grows thinner. 2. The epidermis thickens. 3. The number of Langerhans cells increases. 4. Sweat gland activity increases. Answer: 1 Explanation: 1. The subcutaneous layer thins, leading to a greater risk of hypothermia and pressure ulcers. 2. The thickness of the epidermis decreases, making the skin more fragile and increasing the risk of tears and injury. 3. The number of Langerhans cells decreases, making the older patient more susceptible to infection. 4. Sweat gland activity decreases, resulting in drier skin and decreased perspiration. Page Ref: 465 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

16 ..

17) The nurse is conducting a physical examination of the skin, hair, and nails. Why should the nurse note the age of the patient? 1. It alerts the nurse to expect age-related changes. 2. It validates that skin changes in the older population are pathologic. 3. It reminds the nurse that scaly, dry skin is more common in young adults. 4. It reinforces the concept that age is the most significant risk factor for cancer. Answer: 1 Explanation: 1. The nurse should expect findings related to the aging process. 2. Skin changes related to the aging process are not always pathologic. The nurse must possess the knowledge of normal and abnormal findings for each age group. 3. Scaly, dry skin is not common in young adults. 4. Age is not the most significant risk factor for cancer. Page Ref: 464-465 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

17 ..

18) The nurse is assessing the integumentary status of an older patient. What change should the nurse expect in this patient? 1. Decrease in abdominal fat 2. Increase in perfusion 3. Decrease in vitamin D production 4. Increase in vasomotor response Answer: 3 Explanation: 1. In older adults, there is an increase in abdominal fat due to the redistribution of adipose tissue. 2. Perfusion of the dermis decreases in older adults. 3. Vitamin D production in the epidermis declines in older adults. 4. The vasomotor response of the dermis declines in older adults. Page Ref: 465 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

18 ..

19) During an integumentary assessment, an older patient is found to have a brown benign macule with a defined border. How should the nurse document this finding? 1. Keratosis 2. Angioma 3. Lentigine 4. Telangiectases Answer: 3 Explanation: 1. Keratoses are the horny growths of keratinocytes. 2. Angiomas are benign vascular tumors with dilated blood vessels found in the middle to upper dermis. 3. Lentigines, or liver spots, are brown or black benign macules with a defined border. 4. Telangiectases are single dilated blood vessels, capillaries, or terminal arteries. Page Ref: 464 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

19 ..

20) A patient has an area of rough, thickened, hardened epidermis. What should the nurse suspect as the reason for this skin lesion? 1. Chronic dermatitis 2. Athlete's foot 3. Ear piercing 4. Psoriasis Answer: 1 Explanation: 1. Lichenification is a rough, thickened, hardened area of epidermis resulting from chronic irritation such as scratching or rubbing. An example of lichenification is chronic dermatitis. 2. A fissure is a linear crack with sharp edges, extending into the dermis. Examples include cracks at the corners of the mouth or in the hands, or those seen with athlete's foot. 3. A keloid is an elevated, irregular, darkened area of excess scar tissue caused by excessive collagen formation during healing. It extends beyond the site of the original injury. An example of a keloid is scar tissue from ear piercing. 4. Scales are shedding flakes of greasy, keratinized skin tissue. Examples of scales include dry skin, dandruff, psoriasis, and eczema. Page Ref: 459 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

20 ..

21) A patient has the following laboratory values: sodium 144 mEq/L; potassium 3.8 mEq/L; hemoglobin 8.4 g/dL; glucose 105 mg/dL. Which assessment finding might correlate with these values? 1. Nail plate is separate from the nail bed. 2. Nail folds are inflamed and swollen. 3. Nail is spoon-shaped. 4. Nail has a transverse groove. Answer: 3 Explanation: 1. The nail plate may separate from the nail bed in trauma, psoriasis, and Pseudomonas and Candida infections. This patient's laboratory values do not suggest an infection. 2. The nail folds become inflamed and swollen and the nail loosens in paronychia, an infection of the nails. This patient's laboratory values do not suggest an infection. 3. Normal hemoglobin in men is 13.5-16.5 g/dL. Normal hemoglobin in women is 12.0-15.0 g/dL. Normal sodium is 135-147 mEq/L. Normal potassium is 3.5-5.2 mEq/L. A normal glucose is 60-110 mg/dL. In this scenario, the patient has normal sodium, potassium, and glucose. The hemoglobin is low. Thin, spoon-shaped nails might be seen with anemia. 4. Nail grooves may be caused by inflammation, planus, or nail biting. This patient's laboratory values do not suggest any of these. Page Ref: 463 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.

21 ..

22) A patient with heart failure has 3+ lower extremity edema. Which description should the nurse use to most accurately document this patient's edema? 1. Slight pitting, no obvious distortion 2. Deeper pit, no obvious distortion 3. Pit is obvious, extremities are swollen 4. Pit remains with obvious distortion Answer: 3 Explanation: 1. In 1+ edema, there is slight pitting with no obvious distortion. 2. In 2+ edema, there is a deeper pit, but no obvious distortion. 3. In 3+ edema, the pit is obvious, and the extremities are swollen. 4. In 4+ edema, the pit remains, with obvious distortion. Page Ref: 462 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

22 ..

23) The nurse is caring for a patient with thinning of the nails. Which test result should the nurse use to aid in the diagnosis of this nail disorder? 1. Pulse oximetry 2. Hemoglobin 3. Serum albumin 4. White blood cell count Answer: 3 Explanation: 1. Pulse oximetry measures the oxygen level of the blood. Decreased oxygenation might cause nail thickening. 2. Hemoglobin measures red blood cell oxygen-carrying capacity. If the patient has a hemoglobin problem, the nails would be spoon-shaped. 3. One laboratory test that assesses for nutritional deficiencies is a serum albumin level. This test would help explain thin nails. 4. A white blood cell count is used to check for an infection. The nails would appear to be inflamed or separating from the nail bed. Page Ref: 463 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.

23 ..

24) The nurse documents that a patient has 4+ pitting edema on the lower right tibia. How many millimeters of depression occurred? 1. 2 mm 2. 4 mm 3. 6 mm 4. 8 mm Answer: 4 Explanation: 1. +1 pitting edema is 2 mm of depression. 2. +2 pitting edema is 4 mm of depression. 3. +3 pitting edema is 6 mm of depression. 4. +4 pitting edema is 8 mm of depression. Page Ref: 462 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

24 ..

25) A patient has a flat, nonpalpable change in the skin color on the back. Which characteristic should the nurse use to identify this skin color change as a macule? 1. Smaller than 1 cm, with a circumscribed border 2. Larger than 1 cm with an irregular border 3. Smaller than 0.5 cm 4. Group of lesions larger than 0.5 cm. Answer: 1 Explanation: 1. Macules are smaller than 1 cm, with a circumscribed border. 2. Patches are larger than 1 cm and may have irregular borders. 3. Papules are smaller than 0.5 cm. 4. Plaques are groups of papules that form lesions larger than 0.5 cm. Page Ref: 458 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

25 ..

26) A patient reports having a dark spot on the arm that is "getting bigger and occasionally bleeds." Which additional health information is most relative to this patient's symptoms? Select all that apply. 1. The patient's father had chronic obstructive pulmonary disease. 2. The patient plays golf three or four times a week. 3. The patient is male. 4. There is a history of cardiac disease in the patient's family. 5. The patient is a blue-eyed blonde. Answer: 2, 3, 5 Explanation: 1. A family history of COPD is not a risk factor for skin cancer. 2. A dark spot on the arm that tends to bleed may be skin cancer. Risk factors for skin cancer include extended exposure to sunlight. 3. A dark spot on the arm that tends to bleed may be skin cancer. Risk factors for skin cancer include being male. 4. A family history of cardiac disease is not a risk factor for skin cancer. 5. A dark spot on the arm that tends to bleed may be skin cancer. Risk factors for skin cancer include having light-colored hair and eyes. Page Ref: 457 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

26 ..

27) A patient is diagnosed with albinism. What finding should the nurse expect to assess in this patient? 1. Excessive body hair 2. White patches on the skin 3. Overgrowth of scar tissue 4. Very pale skin Answer: 4 Explanation: 1. Excessive body hair is hirsutism. 2. White patches on the skin are vitiligo. 3. Overgrowth of scar tissue forms keloids. 4. Albinism is an autosomal recessive condition causing hypopigmentation of the skin, hair, and eyes because of an inability to synthesize melanin. Page Ref: 455, 457 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

27 ..

28) An adolescent patient has extensive acne over the face and upper neck. Which factor should the nurse recognize as a reason for this health problem? 1. Inflamed sebaceous glands 2. Blocked endocrine glands 3. Blocked exocrine glands 4. Inflamed ceruminous glands Answer: 1 Explanation: 1. Sebaceous glands produce oil. Oily skin is common in adolescents and young adults. Oily skin may be a normal finding, or it may accompany a skin disorder such as acne vulgaris. If a sebaceous gland becomes blocked, a pimple or whitehead appears on the surface of the skin. 2. Acne is not caused by blocked endocrine glands. 3. Acne is not caused by blocked exocrine glands. 4. Acne is not caused by inflamed ceruminous glands. Page Ref: 455,458 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

28 ..

29) A patient waiting to have a skin biopsy asks what occurs during the procedure. What should the nurse respond to this patient? 1. "Didn't your doctor tell you?" 2. "Maybe you shouldn't have it done." 3. "I'm not sure." 4. "Let me check to see exactly what you are having done and then we can talk more about what you can expect." Answer: 4 Explanation: 1. Answering the patient's inquiry with a question is not therapeutic. 2. The nurse should not discourage the patient from obtaining a prescribed diagnostic test. 3. The nurse needs to find out what occurs during the biopsy. This statement is not sufficient communication. 4. Regardless of the type of diagnostic test, the nurse is responsible for explaining the procedure and any special preparation needed and for supporting the patient. Page Ref: 463 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7.Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.

29 ..

30) The nurse is preparing to assess a patient's integumentary status. Which technique should the nurse use to conduct this assessment? 1. Inspection 2. Inspection and percussion 3. Inspection and palpation 4. Percussion and palpation Answer: 3 Explanation: 1. Physical assessment of the skin, hair, and nails is conducted by inspection and another technique. 2. Physical assessment of the skin, hair, and nails is not done by percussion. 3. Physical assessment of the skin, hair, and nails is conducted by inspection and palpation. 4. Physical assessment of the skin, hair, and nails is not done by percussion. Page Ref: 457 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

30 ..

31) After completing an integumentary status assessment, the nurse documents "+1 edema right lower leg." What does this documentation indicate? 1. Slight pitting, no obvious distortion 2. Deep pitting, no obvious distortion 3. Pitting is obvious, extremities are swollen 4. Pitting remains with obvious distortion Answer: 1 Explanation: 1. The designation +1 means that the patient has slight pitting in the right lower leg with no obvious distortion. 2. The designation +2 means that the patient has deep pitting in the right lower leg with no obvious distortion. 3. The designation +3 means that pitting is obvious, with swollen extremities. 4. The designation +4 means pitting remains with obvious distortion. Page Ref: 462 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

31 ..

32) The nurse is assessing the integumentary status of an older patient. Which finding should the nurse considered expected in this patient? Select all that apply. 1. Keratoses 2. Skin tags 3. Urticaria 4. Photoaging 5. Acne Answer: 1, 2, 4 Explanation: 1. Common skin lesions in older adults include keratoses. 2. Common skin lesions in older adults include skin tags. 3. Urticaria (hives) is an integumentary disorder that is not a normal sign of aging. 4. Common skin lesions in older adults include photoaging. 5. Acne is common in adolescents, not in older adults. Page Ref: 464 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

32 ..

33) The nurse is planning to assess an African American patient's integumentary status. Which finding indicates that this patient has cyanosis? 1. Yellow hue in the eyes 2. Bluish-tinged nail beds 3. Cherry-red lips 4. Orange-green cast to the skin Answer: 2 Explanation: 1. A yellowish hue indicates the presence of jaundice. 2. Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae. 3. Cherry-red lips are associated with carbon monoxide poisoning. 4. An orange-green cast to the skin is not associated with any specific disorder. Page Ref: 455 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

33 ..

34) A patient has the appearance of herpetic lesions found over the nose and mouth region. Which term should the nurse use to document this finding? 1. Scaly 2. Pustular 3. Pruritic 4. Ulcerated Answer: 4 Explanation: 1. Scaly lesions are characteristic of eczema. 2. Pustular lesions are associated with acne. 3. Pruritic refers to itching. 4. Ulcerated is used to describe pressure ulcers, skin cancer, and herpes simplex. Page Ref: 459, 461 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

34 ..

35) During the assessment of an older patient's integumentary status, the nurse notes small areas of hyperpigmentation on the patient's hands. What should the nurse consider as the cause of this finding? 1. Hyperplasia of melanocytes in sun-exposed areas 2. Reduced vitamin D production 3. Decreased blood perfusion of the dermis 4. Redistribution of adipose tissue Answer: 1 Explanation: 1. The nurse is noting "liver spots" or small areas of hyperpigmentation over the patient's hands. This is due to hyperplasia of melanocytes, especially in sun-exposed areas of the epidermis. 2. Alterations in vitamin D production are not associated with excessive pigmentation. 3. Reduced blood perfusion is not associated with excessive pigmentation. 4. Changes in adipose tissue are not associated with excessive pigmentation. Page Ref: 465 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

35 ..

36) A patient is recovering from a biopsy that sampled a small section of dermis and subcutaneous fat. For which type of biopsy should the nurse plan care for this patient? 1. Incisional 2. Punch 3. Excisional 4. Shave Answer: 2 Explanation: 1. The incisional biopsy involves the removal of a portion of a tumor or lesion. 2. A punch skin biopsy is done to differentiate benign lesions from skin cancers. An instrument is used to remove a small section of dermis and subcutaneous fat. The punch biopsy provides a full-thickness specimen for analyzing. 3. The excisional biopsy is the removal of an entire lesion or tumor. 4. The shave biopsy is the scraping of a layer of cells for analyzing. Page Ref: 463 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.

36 ..

37) A patient is scheduled for a test to diagnose for the presence of a herpes infection. For which diagnostic test should the nurse prepare the patient? 1. Patch test 2. Tzanck smear 3. Potassium chloride test 4. Wood's lamp examination Answer: 2 Explanation: 1. Patch testing is used to assess allergens. 2. The Tzanck smear is used to diagnose herpes infections. 3. The potassium chloride test is used to diagnose interstitial cystitis. 4. The Wood's lamp test is used to assess for tinea infections. Page Ref: 464 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the integumentary system.

37 ..

38) The nurse is preparing to assess a patient's integumentary status. What should the nurse do prior to beginning this examination? Select all that apply. 1. Obtain a gown and drape for the patient. 2. Cleanse the blood pressure cuff with alcohol. 3. Obtain several pairs of disposable gloves. 4. Ensure the examination room is warm and private. 5. Place a ruler and flashlight near the examination table. Answer: 1, 3, 4, 5 Explanation: 1. For the examination, the patient will remove all clothing and put on a gown or drape. 2. A blood pressure cuff is not used for this examination. 3. Disposable gloves are worn when palpating lesions, skin surfaces with infections or infestations, or discharge from skin lesions and mucous membranes. 4. The examination should be conducted in a warm, private room. 5. A ruler is used to measure the size of lesions. A flashlight is used to better visualize lesions. Page Ref: 457 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.2 Outline the components of the assessment of the integumentary system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the integumentary system.

38 ..

39) The nurse is caring for an older patient with thin subcutaneous tissue. What action should the nurse take to ensure the patient's comfort and safety? Select all that apply. 1. Apply warm blankets. 2. Keep the room cool. 3. Use a lift sheet to reposition in bed. 4. Assess skin for areas of breakdown. 5. Encourage frequent position changes. Answer: 1, 3, 4, 5 Explanation: 1. The older patient with thin subcutaneous tissue is at risk for hypothermia. Applying warm blankets will reduce this risk. 2. The older patient with thin subcutaneous tissue is at risk for hypothermia. The room should be warm, not cool. 3. Using a lift sheet to reposition in bed will reduce the risk of skin tears because of the flattened dermal-epidermal junction. 4. The older patient with thin subcutaneous tissue is at risk for pressure ulcer formation. Assessing the skin for areas of breakdown is an action to reduce this risk. 5. The older patient with thin subcutaneous tissue is at risk for pressure ulcer formation. Frequent position changes will reduce this risk. Page Ref: 465 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 15.3 Differentiate considerations for assessing the integumentary system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae from complex congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

39 ..

40) During an integumentary assessment the nurse observes multiple areas of ecchymosis over the patient's arms, legs, and upper back. What problem should the nurse consider as a cause of these manifestations? Select all that apply. 1. Septicemia 2. Hemophilia 3. Liver disease 4. Vitamin C deficiency 5. Vitamin K deficiency Answer: 2, 3, 4, 5 Explanation: 1. Petechiae can be caused by septicemia. 2. Ecchymosis can be caused by hemophilia. 3. Ecchymosis can be caused by liver disease. 4. Ecchymosis can be caused by Vitamin C deficiency. 5. Ecchymosis can be caused by Vitamin K deficiency. Page Ref: 460 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

40 ..

41) The nurse suspects that a school-age child has ringworm of the scalp. What did the nurse assess to come to this conclusion? Select all that apply. 1. Coarse, dry hair 2. Areas of hair loss 3. Scaling on the scalp 4. Pustules on the scalp 5. Oval nits on the hair shaft Answer: 2, 3, 4 Explanation: 1. Coarse, dry hair is associated with hypothyroidism. 2. Hair loss is associated with tinea capitis or scalp ringworm. 3. Scales on the scalp are associated with tinea capitis or scalp ringworm. 4. Pustules on the scalp are associated with tinea capitis or scalp ringworm. 5. Oval nits on the hair shaft are associated with head lice. Page Ref: 462 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

41 ..

42) Prior to assessing a patient's integumentary status, the nurse notes excessive perspiration. What should the nurse consider as a possible cause for this finding? Select all that apply. 1. The patient is hungry. 2. The patient is anxious. 3. The patient is in shock. 4. The patient has a fever. 5. The patient has been exercising. Answer: 2, 3, 4, 5 Explanation: 1. Excessive perspiration is not associated with hunger. 2. Excessive perspiration may be associated with anxiety. 3. Excessive perspiration may be associated with shock. 4. Excessive perspiration may be associated with fever. 5. Excessive perspiration may be associated with increased activity. Page Ref: 461 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 15.1 Describe the anatomy, physiology, and functions of the skin, hair, and nails, and identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 3. Interpret abnormal findings of the integumentary system collected during assessment.

42 ..

43) The nurse is preparing a brochure on sun safety for a community health fair. Which information should the nurse include? Select all that apply. 1. Limit the use of tanning booths. 2. Apply sunscreen when near sand, snow, concrete, or water. 3. Limit exposure to the sun between the hours of 10 am and 3 pm. 4. Apply sunscreen with an SPF of 15 or more every hour if sweating heavily. 5. Wear a wide-brimmed hat, long-sleeved shirt, and long pants when in the sun. Answer: 2, 3, 4, 5 Explanation: 1. Tanning booths should be avoided since the ultraviolet rays emitted by these devices damage the deep skin layers. 2. Sunscreen should be applied when near sand, snow, concrete, or water because these materials can reflect more than 50% of ultraviolet rays onto the skin. 3. Exposure to the sun should be minimized between the hours of 10 am and 3 pm because this is when the ultraviolet rays are the strongest. 4. A waterproof or water-resistant sunscreen with an SPF of 15 or greater should be applied every hour if sweating heavily. 5. A wide-brimmed hat, long-sleeved shirt, and long pants should be worn when in the sun to protect the skin from ultraviolet light exposure. Page Ref: 465-466 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science; Knowledge; Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

43 ..

44) The nurse is preparing to demonstrate the Slip! Slop! Slap! Wrap! method to prevent sun exposure. Which items should the nurse have available for the demonstration? Select all that apply. 1. Hat 2. Umbrella 3. Sunglasses 4. Long-sleeved shirt 5. Sunscreen of SPF 15 or higher Answer: 1, 3, 4, 5 Explanation: 1. With the Slip! Slop! Slap! Wrap! method to prevent sun exposure, a hat is "slapped" on. 2. An umbrella is not used with the Slip! Slop! Slap! Wrap! method to prevent sun exposure. 3. With the Slip! Slop! Slap! Wrap! method to prevent sun exposure, sunglasses are "wrapped" on. 4. With the Slip! Slop! Slap! Wrap! method to prevent sun exposure, a long-sleeved shirt is "slipped" on. 5. With the Slip! Slop! Slap! Wrap! method to prevent sun exposure, sunscreen of SPF 15 or higher is "slopped" on. Page Ref: 466 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.B.13. Assess own level of communication skill in encounters with patients and families | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Knowledge and Science; Knowledge; Integration of knowledge from nursing and other disciplines | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 15.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the integumentary system collected during assessment and health promotion activities to support the health of this body system.

44 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 16 Nursing Care of Patients with Integumentary Disorders 1) The parent of an adolescent voices concerns about the child's acne. Which response by the nurse is best? 1. "The skin needs to be washed at least twice a day with mild soap and water to remove surface oil." 2. "The greatest culprit for acne is dietary habits, not inadequate hygiene." 3. "Are you embarrassed by her appearance?" 4. "What are your concerns about her hygiene practices?" Answer: 1 Explanation: 1. The teaching plan for the patient with acne includes general guidelines for skin care and health as well as specific guidelines for care of the acne lesions. The face should be washed with a mild soap and water at least twice a day to remove accumulated oils. 2. Dietary intake is not the primary cause of acne. 3. It would be premature to address the potential for the parent to be embarrassed about the adolescent's health problem. 4. Hygiene is not the primary cause of acne. Page Ref: 491 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with integumentary disorders.

1 ..

2) A patient has a 3 cm in diameter lesion in the left axilla that is deep, painful, and contains pus. Which type of lesion should the nurse document in the patient's medical record? 1. Furuncle 2. Folliculitis 3. Carbuncle 4. Herpes varicella Answer: 1 Explanation: 1. A furuncle develops when the infection from folliculitis becomes deeper. It is initially a deep, firm, red, painful nodule from 1 to 5 cm in diameter. 2. In folliculitis, a sebaceous gland is obstructed, causing a deep inflammatory reaction and infection most commonly from S. aureus. The lesions appear as pustules surrounded by an area of erythema on the surface of the skin and are accompanied by discomfort ranging from slight burning to intense itching. 3. A carbuncle is a group of infected hair follicles that interconnect. It is about 3 to 10 cm in diameter. 4. Herpes varicella (chickenpox) lesions are superficial and usually limited to the face, scalp, and chest. Page Ref: 478 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

2 ..

3) An African American patient has reoccurring folliculitis on the face. What should the nurse instruct the patient to do about this health problem? 1. Practice good hygiene. 2. Shave daily. 3. Shave very closely. 4. Shave in the opposite direction of hair growth. Answer: 1 Explanation: 1. Careful hand hygiene is one of the most effective methods to reduce the spread of infection. All patients should be taught the importance of hand hygiene, but it is even more important for the patient with a bacterial infection. 2. There is no evidence that daily shaving will reduce folliculitis. 3. There is no evidence that shaving closely will reduce folliculitis. 4. There is no evidence that shaving in the opposite direction of hair growth will reduce folliculitis. Page Ref: 479 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with integumentary disorders.

3 ..

4) A patient has atopic dermatitis (eczema) with a secondary infection. What should the nurse emphasize when teaching to prevent this type of infection in the future? 1. Methods to prevent itching 2. Continuous antibiotic treatment 3. Frequent bathing 4. Allergy testing Answer: 1 Explanation: 1. A secondary infection can develop due to skin trauma and breakdown from scratching. Therefore, it is important to control the itching that occurs with eczema. 2. Antibiotics would be given to treat the infection but not prevent it. 3. Frequent bathing may dry out the skin causing increased itching. 4. It is important to identify the irritants that cause the lesions, but this will not prevent a secondary infection. Page Ref: 487 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; Environmental health; health promotion/disease prevention (e.g., transmission of disease, disease patterns, epidemiological principles); chronic disease management; healthcare systems; transcultural approaches to health; family dynamics | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

4 ..

5) A patient who has a small, red, scaling lesion that is sitting on an elevated base on the forehead states the lesion began several weeks before and will not heal. What type of lesion does the nurse consider the patient is experiencing? 1. Squamous cell carcinoma 2. Melanoma 3. Psoriasis 4. Seborrheic keratosis Answer: 1 Explanation: 1. Squamous cell carcinoma consists of tumors of the outer epidermis that occur with frequent exposure to the sun. The scaling lesions sit on an elevated base with an irregular border that may itch or be a nonhealing lesion after minor trauma. 2. Melanomas appear as a changing or unusual mole with an irregular border, an uneven surface, and a varying size and shape. 3. Psoriasis lesions are erythematous papules and plaques with silver-white scales that are sharply demarcated. 4. Seborrheic keratosis lesions are warty, dirty yellow to black papules with sharp margins. Page Ref: 495 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

5 ..

6) A patient diagnosed with scabies asks how the disorder was "caught." What information should be provided to the patient? 1. The disorder is transmitted by contact with infected persons or their possessions. 2. The disorder is transmitted by the feces of infected animals. 3. Scabies is a bacterial infection transmitted by direct contact with infected persons. 4. Scabies is a fungal infection transmitted by contact with infected respiratory secretions. Answer: 1 Explanation: 1. Scabies is transmitted via contact with infected people or their contaminated articles. 2. Scabies is the result of infestation of the itch mite. 3. Scabies is a parasitic disorder. 4. Scabies is not a bacterial, viral, or fungal disorder. Page Ref: 483 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

6 ..

7) The nurse is planning care for a patient with herpes zoster. Which problem should the nurse identify as being the priority for this patient? 1. Managing pain 2. Avoiding breakouts 3. Relieving itchiness 4. Improving hygiene Answer: 1 Explanation: 1. The patient with herpes zoster often experiences severe pain over the entire dermatome supplied by the affected nerve root. Managing pain would be the priority for this patient. 2. Herpes zoster can only be prevented or reduced by having the varicella vaccination. 3. Itchiness might occur when the lesions begin to heal; however, the priority is to treat the pain. 4. Herpes zoster does not occur because of poor hygiene. Page Ref: 484 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

7 ..

8) A patient with herpes zoster has pruritus and reports difficulty resting at night. Which intervention will best help the patient? 1. Encourage to take prescribed antipruritic agents approximately one hour before bedtime. 2. Massage the irritated skin areas with lotion. 3. Apply powder to the lesions. 4. Use heavy bed linens to avoid chilling at night. Answer: 1 Explanation: 1. A patient with herpes zoster might express difficulty sleeping. The inability to rest is often related to pruritus. The use of antipruritic agents prior to bedtime will facilitate rest. 2. Although lotion may be prescribed for the lesions, it should not be massaged into the skin. 3. Powder can irritate the skin lesions. 4. Heat will increase the occurrence of itching. Page Ref: 485 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

8 ..

9) The nurse is planning care for a patient at risk for a pressure injury. What should the nurse include in this patient's plan of care? Select all that apply. 1. Initiate a frequent toileting schedule. 2. Turn the patient every 2 hours. 3. Massage pressure areas with lotion every 4 hours. 4. Use inflatable doughnut rings to reduce pressure on the sacrum. 5. Use hot water to cleanse the skin immediately after incontinence. Answer: 1, 2 Explanation: 1. Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. 2. The patient should be turned at least every 2 hours. 3. Massage of pressure areas can cause friction and damage to problem skin areas. 4. Inflatable doughnut rings are contraindicated, as they increase pressure and reduce perfusion to affected areas. 5. Use of hot water for cleansing may cause skin injury. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with integumentary disorders.

9 ..

10) The nurse is preparing a teaching tool to reduce the incidence of pressure injuries. Which patient characteristic should the nurse identify as being at an increased risk for this health problem? Select all that apply. 1. Restricted activity 2. Decreased sensation 3. Very thin 4. Urinary and fecal incontinence 5. Good nutrition Answer: 1, 2, 3, 4 Explanation: 1. Patients who have restricted activity, as would occur with quadriplegia, strokes, and fractured hips, are at risk for a pressure injury. 2. Decreased sensation prevents patients from feeling the pain associated with the development of a pressure injury, which increases the risk of development and progression. 3. Patients who are very thin or have decreased protein in the diet have skin that is more likely to ulcerate. 4. Patients who have urinary or fecal incontinence or are exposed to other types of moisture such as perspiration, wound drainage, or emesis are more prone to pressure injuries 5. Patients with good nutrition are at a decreased risk for a pressure injury. Page Ref: 503-504 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

10 ..

11) The nurse is assessing a patient's risk for a pressure injury. Which factors should the nurse include in this assessment? Select all that apply. 1. Sensory perception 2. Moisture 3. Mobility 4. Nutrition 5. Social interaction Answer: 1, 2, 3, 4 Explanation: 1. Decreased sensation increases the risk for a pressure injury. 2. Moisture increases skin breakdown, thereby increasing the risk for a pressure injury. 3. Decreased mobility level increases the risk for a pressure injury due to prolonged pressure in one area. 4. Nutrition supplementation is an essential intervention for a pressure injury. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization. 5. The patient's social interaction is not a risk level since a chair-bound person may be able to socialize, but not move. Page Ref: 504 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

11 ..

12) The nurse is planning care for a patient who is at risk for a pressure injury. Which action should be included in this patient's plan of care? Select all that apply. 1. Use pillows to offload pressure. 2. Turn at least every 2 hours. 3. Use a mild cleansing agent on the skin. 4. Keep on bed rest. 5. Pull up in bed every 2 hours or less. Answer: 1, 2, 3 Explanation: 1. Pillows provide a cushion for bony prominences, which decreases pressure. 2. Turning every 2 hours takes prolonged pressure off a single area. 3. Mild cleansing agents are less likely to remove the skin's natural barrier. 4. Keeping a patient on bed rest would be inappropriate because activity and mobility prevent prolonged pressure in one area. 5. Pulling patients up in bed increases friction and shear but does not prevent pressure. Page Ref: 506-507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Read and interpret data; apply health promotion/disease prevention strategies | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

12 ..

13) A patient asks about options to treat a malignant melanoma lesion on her arm. How should the nurse respond to this patient? 1. "The preferred method of treatment is to remove all the cancer surgically." 2. "An anti-cancer cream will be used to dissolve the lesion." 3. "You will receive radiation to the skin lesion as a first method of treatment." 4. "You will receive intravenous chemotherapy as a first method of treatment" Answer: 1 Explanation: 1. Surgical excision is the preferred treatment for malignant melanoma. 2. A topical cream would not be used for a melanoma. 3. Radiation is most often used for lesions that are inoperable because of location, which is not the case here. 4. Intravenous chemotherapy would not be used for a localized skin lesion. Page Ref: 498 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

13 ..

14) A patient with a basal cell carcinoma of the nose is scheduled for curettage and electrodesiccation to remove the lesion. Which criteria were used to select this procedure? Select all that apply. 1. The lesion must measure less than 2 cm in diameter. 2. The lesion must be superficial. 3. The lesion must measure at least 4 cm in diameter. 4. The lesion must be in an area where the dermis is thin. 5. The lesion must extend into the subcutaneous tissue. Answer: 1, 2 Explanation: 1. Curettage and electrodesiccation are used to treat basal cell carcinomas that are less than 2 cm in diameter. 2. Curettage and electrodesiccation are used to treat basal cell carcinomas that are superficial. 3. Curettage and electrodesiccation are not used for lesions that are larger. 4. Curettage and electrodesiccation are not used where the dermis is thin. 5. Curettage and electrodesiccation are not used where the tumor extends into the subcutaneous tissue. Page Ref: 496 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

14 ..

15) A patient scheduled for Mohs surgery for basal cell skin cancer asks how long the procedure will take. How should the nurse respond to this patient? Select all that apply. 1. "The procedure occurs in steps, and time needed depends on your lesion." 2. "The time depends on how deep the lesion is." 3. "It is difficult to predict how long the procedure will take." 4. "This is a long, complicated procedure and may take all day." 5. "The procedure should be completed in an hour or less." Answer: 1, 2, 3 Explanation: 1. The procedure proceeds in stages until the tumor is entirely removed. Depending on the depth of the lesion, it may take a short time or a long time. 2. Depending on the depth of the lesion, it may take a short time or a long time. 3. It is difficult to predict in advance. 4. There is no way of knowing how long the procedure will take to complete. 5. There is no way of knowing how long the procedure will take to complete. Page Ref: 496 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

15 ..

16) A patient has had cryosurgery to treat a skin lesion. What instructions should be given to the patient and family on discharge? Select all that apply. 1. The effects may not be seen for 24 hours. 2. Apply a topical antibiotic as ordered. 3. Keep the treated areas clean. 4. Healing may take several weeks. 5. Healing should occur in a few days. Answer: 1, 2, 3, 4 Explanation: 1. It may take 24 hours for the effects to become obvious. 2. Postoperatively, infection is prevented by applying a topical antibiotic. 3. Postoperatively, infection is prevented by keeping the treated areas clean. 4. Healing occurs in 2 to 3 weeks. 5. Healing occurs in 2 to 3 weeks. Page Ref: 509 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

16 ..

17) A patient with a history of tinea pedis reports concerns about developing the disorder again. Which suggestion should the nurse make to reduce the likelihood of a reoccurrence? 1. Wear sandal-style footwear. 2. Begin to wear cotton undergarments. 3. Soak affected extremities in salted water nightly. 4. Apply lotions to moisturize potential areas of outbreak daily. Answer: 1 Explanation: 1. Tinea pedis is a fungal infection of the soles of the feet, toes, and toenails. The condition is chronic, and can be seen more when the feet are hot and perspire. Wearing of open-style shoes such as sandals would allow the feet to be open to air. 2. Cotton undergarments would not impact tinea pedis. They could assist in the management of tinea corporis. 3. Salt water is not associated with the management of tinea pedis. 4. Lotions would increase moisture to the areas and potentially cause additional problems. Page Ref: 31 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

17 ..

18) Several individuals from a homeless shelter have been diagnosed with pediculosis. What should the nurse include when training the staff on the control and prevention of this infestation? Select all that apply. 1. Pediculosis is spread by contact with personal items such as hats and blankets. 2. Pediculosis is more common in people with lack of proper facilities for bathing and washing clothes. 3. Pediculosis is associated with wearing woolen hats. 4. Pediculosis affects children only. 5. Pediculosis is infestation by mites. Answer: 1, 2 Explanation: 1. Pediculosis is a contagious infestation with lice transmitted by personal contact. The lice live in clothing fibers and are transmitted primarily by contact with infested clothing and bed linens. 2. Pediculosis is more common in people with lack of proper facilities for bathing and washing clothes. 3. Pediculosis can be spread through infested clothing and bed linens. 4. Anyone can contract pediculosis. 5. Infestation by mites is scabies, not pediculosis. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.7 Describe the pathophysiology and manifestations of disorders of the hair and nails, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

18 ..

19) The nurse is reviewing the health history of a patient with alopecia. What should the nurse recognize as a possible cause for this disorder? Select all that apply. 1. Thyroid disorder

2. Systemic lupus erythematosus 3. Three months of chemotherapy for cancer 4. Androgenic causes 5. An overactive pituitary Answer: 1, 2, 3, 4 Explanation: 1. Systemic causes of alopecia can include thyroid disorders. 2. Systemic causes of alopecia can include systemic lupus erythematosus. 3. Numerous drugs can cause alopecia, including many chemotherapeutic drugs used to treat cancer. 4. Hair loss from androgenic causes may occur in postmenopausal women. 5. Systemic causes of alopecia can include pituitary insufficiency, not pituitary over-secretion. Page Ref: 513 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.7 Describe the pathophysiology and manifestations of disorders of the hair and nails, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

19 ..

20) For several months a patient has been experiencing an infection of the cuticle involving several fingernails on both hands. Which type of employment should the nurse suspect is causing this patient's health problem? 1. Dish washer 2. Construction worker 3. Painter 4. Carpenter Answer: 1 Explanation: 1. The chronic form of paronychia (an infection of the cuticle of the fingernails or toenails) is seen most often in people who have frequent exposure to water. 2. Construction workers could develop paronychia from trauma and subsequent secondary infection related to the employment, but they are more likely to have an acute form that begins with painful inflammation and may progress to an abscess. 3. Painters could develop paronychia from trauma and subsequent secondary infection related to the employment, but they are more likely to have an acute form that begins with painful inflammation and may progress to an abscess. 4. Carpenters could develop paronychia from trauma and subsequent secondary infection related to the employment, but they are more likely to have an acute form that begins with painful inflammation and may progress to an abscess. Page Ref: 514 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.7 Describe the pathophysiology and manifestations of disorders of the hair and nails, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

20 ..

21) A female patient is prescribed tretinoin (Retin-A). What should the nurse instruct the patient about this medication? Select all that apply. 1. Wear protective clothing when out of doors. 2. Avoid the use of vitamin A supplements. 3. Use caution when driving at night. 4. Apply to clean, dry skin. 5. Use a reliable form of contraception one month prior to and during use of the medication. Answer: 1, 4 Explanation: 1. The medication could cause hypersensitivity to sun. 2. There is no reason to avoid the use of vitamin A supplements. 3. There is no need to exercise caution during night driving when using this medication. 4. The medication should be applied to clean, dry skin. 5. There is no need to alter birth control approaches when using this medication. Page Ref: 491 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.3 Describe the pathophysiology and manifestations of inflammatory disorders of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

21 ..

22) A patient with psoriasis is being treated with topical corticosteroids. What should the nurse instruct the patient about the use of this medication? 1. Apply in a thin layer. 2. Avoid rubbing into the skin. 3. Apply a thick layer. 4. Continue medication even if lesions worsen. Answer: 1 Explanation: 1. Topical corticosteroids should be applied in a thin layer. 2. Topical corticosteroids should be rubbed in thoroughly on wet skin. 3. Topical corticosteroids should be applied in a thin layer. 4. Some infections may be made worse by corticosteroids. If the lesions worsen, the medication should be discontinued and the health provider notified. Page Ref: 489 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

22 ..

23) The nurse instructs a patient who is prescribed oral griseofulvin for a fungal infection of the nails to take the medication with food. Which foods should the nurse recommend to the patient? Select all that apply. 1. Ice cream 2. Cheese 3. Crackers 4. Pretzels 5. Alcohol Answer: 1, 2 Explanation: 1. The medication should be taken with meals or food high in fat such as ice cream to avoid stomach upset and to help with absorption. 2. The medication should be taken with meals or food high in fat such as cheese to avoid stomach upset and to help with absorption. 3. Crackers and pretzels are high-carbohydrate, lower fat foods. 4. Crackers and pretzels are high-carbohydrate, lower fat foods. 5. Alcohol should be avoided since it may cause rapid pulse and flushing in patients prescribed griseofulvin. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

23 ..

24) A patient with a history of pruritis reports less itching when allergy medicine is used. Which should the nurse consider as the reason for the improvement in symptoms? 1. The allergy medication is reducing histamine release. 2. The patient is distracted from the itching because of the allergies. 3. The patient's pruritis is improving. 4. The patient is taking other medication the nurse is not aware of. Answer: 1 Explanation: 1. The irritant that causes the itching releases histamine. Antihistamines may relieve pruritis for some patients. 2. The allergies are the cause of the itching. 3. Pruritis is improving as a result of the medication blocking the histamine release. 4. There is no indication the patient is taking other medications. Page Ref: 489 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 16.3 Describe the pathophysiology and manifestations of inflammatory disorders of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

24 ..

25) A patient with a history of sun exposure is concerned about broken blood vessels on the cheeks. What should the nurse realize this patient is describing? 1. Telangiectases 2. Nevus flammeus 3. Venus lakes 4. Skin tags Answer: 1 Explanation: 1. Telangiectases are single dilated capillaries or terminal arteries that appear most often on the cheeks and nose. These lesions are more common in older adults and result from photoaged skin. The lesions look like broken veins. 2. Nevus flammeus is a congenital vascular condition involving the capillaries. 3. Venus lakes are small, flat, blue blood vessels. 4. Skin tags are soft papules on a pedicle. Page Ref: 473 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

25 ..

26) A patient is receiving the first ultraviolet light therapy treatment for psoriasis. What should be included in this patient's teaching? 1. The skin will appear reddened approximately eight hours after the treatment. 2. The treatment will be the same length every time. 3. There is no anticipated damage to the eyes or mucous membranes. 4. This is the treatment of choice for patients with psoriasis on 10% of the body. Answer: 1 Explanation: 1. Patients with generalized psoriasis or with psoriasis over 30% of the body will most likely be treated with phototherapy. The patient can expect areas of erythema approximately eight hours after the treatment. 2. The treatment is measured in seconds with a gradual increase in exposure times. 3. To avoid damage to the eyes, they will need to be shielded during the treatment. 4. Patients with generalized psoriasis or with psoriasis over 30% of the body will most likely be treated with phototherapy. Page Ref: 475 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

26 ..

27) A female is experiencing eyelid redness and edema. What would be appropriate for the nurse to include in the assessment of this patient? 1. Ask if eye makeup is thoroughly removed. 2. Ask if swimming in a public pool has recently occurred. 3. Ask the patient if legs are routinely shaved. 4. Ask if facial soap has recently been changed. Answer: 1 Explanation: 1. This patient is experiencing folliculitis, a bacterial infection of the hair follicle on the eyelid. This condition is found more frequently on the scalp and extremities. When found on the eyelids, it is called a stye. It is caused by a bacterial infection of the hair follicle, most commonly caused by Staphylococcus aureus. Not removing makeup could potentiate the development of this disorder. 2. An infection caused by the swimming pool would encompass the entire body. 3. Shaving would involve the legs. 4. The complaints are not generalized on the face but localized in the eye area, so the facial soap is not the culprit. Page Ref: 477 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with integumentary disorders.

27 ..

28) A school-age child is reported to frequently scratch the scalp and the hair "is clumpy and smells really bad." What should the nurse instruct the parent to do? 1. Suggest that the patient be checked for head lice. 2. Suggest that the patient have a blood glucose level drawn. 3. Suggest that the patient wash the hair. 4. Suggest that the patient have a haircut. Answer: 1 Explanation: 1. Pediculosis capitis is an infestation with head lice. Manifestations of head lice include pruritis, scratching, and erythema of the scalp. If untreated, the hair appears matted and crusted with a foul-smelling substance. 2. There are no indications from the information provided that the child has diabetes. 3. Although hygiene may be an issue, the greatest indicator points toward the presence of head lice. 4. There is no need to encourage a haircut at this time. Page Ref: 482 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

28 ..

29) An older patient seeks medical attention for a "strange painful rash" located on the left side of the upper chest. Which health problem should the nurse suspect this patient is experiencing? 1. Herpes zoster 2. Herpes simplex 3. Verruca plana 4. Condylomata acuminata Answer: 1 Explanation: 1. This patient is most likely experiencing herpes zoster. Vesicles appear on the skin and usually appear unilaterally on the face, trunk, or thorax. The patient often experiences severe pain for up to 48 hours before and during eruption of the lesions. The pain may continue for weeks to months. 2. Herpes simplex is usually located on the face, mouth, or genital regions. 3. The clinical manifestations that this patient reports are inconsistent with verruca. 4. The clinical manifestations that this patient reports are inconsistent with condylomata. Page Ref: 484 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

29 ..

30) A female patient seeks medical attention for an itchy reddened area on both hands. Which technique should the nurse use when assessing this patient? 1. Ask if soap or perfume have been recently changed. 2. Ask to remove both shoes and stockings. 3. Auscultate lung sounds. 4. Assess hand grasp strength. Answer: 1 Explanation: 1. This patient's description is consistent with contact dermatitis. This is caused by a hypersensitivity response or chemical irritation. The major sources known to cause contact dermatitis are dyes, perfumes, poison plants, chemicals, or metals. A focused assessment is indicated. 2. There are no reports of the rash on the legs or feet. 3. Respiratory complications are not present. 4. It is not necessary to assess this patient's musculoskeletal strength. Page Ref: 488 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

30 ..

31) A middle-aged female patient reports "strange pimples" over the buttocks region. Which health problem should the nurse suspect this patient is experiencing? 1. Acne conglobata 2. Contact dermatitis 3. Acne vulgaris 4. Acne rosacea Answer: 1 Explanation: 1. Acne conglobata is a chronic type of acne of unknown cause that begins in middle adulthood. It causes serious skin lesions consisting of comedones, papules, pustules, nodules, cysts, and scars. This acne occurs primarily on the back, buttocks, and chest. 2. Contact dermatitis is manifested as a raised, reddened area that appears as a rash and can occur anywhere on the body, affecting individuals of all ages. 3. Acne vulgaris is found in preadolescents, adolescents, and young adults and occurs on the face and shoulders. 4. Acne rosacea appears as a red, blotchy area and is limited to the face. Page Ref: 490 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

31 ..

32) The nurse is preparing a teaching plan about acne for a group of adolescents. What should be included in this teaching plan? Select all that apply. 1. Sun exposure is permitted when protected with sunscreen, but avoid sunburn. 2. Keep hair clean with frequent shampoos. 3. Avoid eating greasy foods. 4. Wash the affected skin area at least six times per day. 5. Squeeze pimples when they occur. Answer: 1, 2 Explanation: 1. The teaching plan for the patient with acne should include exposing the skin to sunlight but avoiding sunburn. 2. The teaching plan for the patient with acne should include shampooing the hair often enough to prevent oiliness. 3. The teaching plan for the patient with acne should include eating a regular, well-balanced diet as foods do not cause or increase acne. 4. The teaching plan for the patient with acne should include washing the skin with a mild soap and water at least twice a day. 5. The teaching plan for the patient with acne should include trying to avoid putting hands on the face and not squeezing pimples. Page Ref: 491 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

32 ..

33) A patient with fair skin and blond hair is diagnosed with basal cell cancer on the face and forehead. What should the nurse include when teaching this patient about the diagnosis? 1. This type of skin cancer tends to reoccur. 2. This is a virulent form of skin cancer. 3. This type of skin cancer should be left alone. 4. This type of skin cancer is rare. Answer: 1 Explanation: 1. Basal cell cancer tends to reoccur. Tumors larger than 2 cm have a high rate of return. 2. Basal cell cancer is the least aggressive type of skin cancer. Malignant melanoma is the most virulent form of skin cancer. 3. No cancer should be left alone. 4. Basal cell cancer is the most common type of skin cancer. Page Ref: 494 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

33 ..

34) A patient with skin cancer is recovering from a surgical procedure in which the layers of the lesion were shaved off. For which procedure should the nurse prepare teaching for this patient? 1. Mohs surgery 2. Complete surgical excision of the lesion 3. Curettage 4. Electrodesiccation Answer: 1 Explanation: 1. In Mohs surgery, thin layers of the tumor are horizontally shaved off. A frozen section of the tissue is stained at each level to determine tumor margins. 2. A surgical excision is the total removal of the lesion, not just layers. 3. Curettage is the shaving of abnormal tissue within 1 to 2 mm of the margin. 4. Electrodesiccation refers to the use of a low-voltage transmission to the base of the tumor. Page Ref: 496 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

34 ..

35) A patient is diagnosed with advanced malignant melanoma. What should the nurse consider when planning care for this patient? 1. The prognosis is uncertain. 2. Age of the patient has no impact on the prognosis. 3. The disease will be completely cured with surgery. 4. The patient will need chemotherapy and radiation. Answer: 1 Explanation: 1. The prognosis for survival for people diagnosed with malignant melanoma is determined by tumor thickness, ulceration, metastasis, site, age, and gender. 2. Younger patients and women have a somewhat better chance of survival. 3. There is no evidence that the patient will be completely cured with surgery. 4. There is no evidence that the patient will need chemotherapy and radiation. Page Ref: 497 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

35 ..

36) The nurse instructs a patient with melanoma to "eat foods rich in protein and calories." For which health problem is this action most likely being directed? 1. Changes in skin integrity 2. Insufficient blood flow 3. Altered oxygen to blood tissues 4. Insufficient body fluid Answer: 1 Explanation: 1. When planning care for a patient with changes in skin integrity, interventions should include monitoring for infection, wound care, careful hand hygiene, and adequate caloric and protein intake for wound healing. 2. Dietary alterations will not help with insufficient blood flow. 3. Dietary alterations will not help with oxygenation. 4. Fluid volume is not directly impacted by a diet high in protein and calories. Page Ref: 500 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.5 Describe the risk factors for and pathophysiology and manifestations of malignant skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

36 ..

37) A patient confined to bed has slid to the bottom of the bed. What should the nurse do to adjust this patient's body position? 1. Lift the patient up in bed. 2. Pull the patient up in bed. 3. Slide the patient up in bed. 4. Do nothing. Answer: 1 Explanation: 1. Patients in hospital beds are subject to shearing forces when the head of the bed is elevated and the torso slides down toward the foot of the bed. Pulling up or sliding the patient when in bed subjects the patient to shearing forces. For this reason, always lift patients up in bed with the assistance of support staff as indicated. 2. Pulling up the patient when in bed subjects the patient to shearing forces. 3. Sliding the patient when in bed subjects the patient to shearing forces. 4. Doing nothing is not appropriate for the patient confined to bed. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

37 ..

38) A patient in a wheelchair has a history of sacral pressure injuries. What instruction should be included in the patient's teaching? 1. Shift the weight every 15 minutes to 1 hour. 2. Sit on a doughnut. 3. Stay in one position as long as possible. 4. Have a family pull the patient up in the wheelchair. Answer: 1 Explanation: 1. Sitting uninterrupted in a wheelchair should be avoided. The patient should be repositioned every hour. If the patient can move, teach him or her to shift the weight every 15 minutes. 2. Avoid the use of doughnut devices because they cause a reduction in blood perfusion and contribute to a pressure injury. 3. Sitting uninterrupted in a wheelchair should be avoided. 4. Pulling the patient up in the chair may result in skin shear. Page Ref: 507 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

38 ..

39) A middle-aged male patient says, "I wish I could have all of these tattoos removed." What solution should the nurse suggest to this patient? 1. Dermabrasion 2. Chemical peeling 3. Skin graft 4. Blepharoplasty Answer: 1 Explanation: 1. Dermabrasion is a method of removing facial scars, severe acne, and pigment from unwanted tattoos. The area is sprayed with a chemical to cause light freezing and is then abraded with sandpaper or a revolving wire brush to remove the epidermis and a portion of the dermis. 2. Chemical peeling involves a process that smooths the skin by removing the surface layers. 3. Skin grafting involves removing skin from another body area and will cause scarring; it is not an acceptable management tool for this patient's problem. 4. Blepharoplasty is a cosmetic surgical procedure on the eyes. This cannot be used to remove the tattoos. Page Ref: 510 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

39 ..

40) A middle-aged patient recovering from a facelift says, "I think this was a waste of time and money. I look horrible!" How should the nurse respond to this patient? 1. "It takes a while for the skin to heal." 2. "You could use makeup." 3. "I would complain to the doctor." 4. "What did you expect?" Answer: 1 Explanation: 1. This patient needs to be reminded that there will be bruising and swelling that might take several weeks to disappear. It might also take a year for healing to complete and the final results to appear. The patient's reports are normal when faced with an alteration in appearance. 2. The use of makeup is not needed and is premature. 3. Filing a complaint with the doctor is not indicated. 4. The patient's emotional state warrants an empathetic response; asking the patient what he or she expected is not a therapeutic response. Page Ref: 512 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

40 ..

41) A patient with a skin disorder is prescribed a therapeutic bath to be used at home. What should the nurse include when teaching the patient about this treatment? Select all that apply. 1. Place a bath mat in the tub. 2. Stay in the tub bath for 1 hour. 3. Keep the bathroom well-ventilated. 4. Rub the skin vigorously with a dry towel. 5. Expect the skin to be itchy after the bath. Answer: 1, 3 Explanation: 1. A bath mat should be used in the tub because medications may cause the tub to become slippery. 2. The patient should be instructed to stay in the tub for 20 to 30 minutes and immerse the area being treated. 3. The bathroom should be well-ventilated when using medications in a bath. 4. The skin should be blotted and not rubbed with a towel. 5. If itching is not relieved or becomes worse, the healthcare provider should be contacted. Page Ref: 472 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with integumentary disorders.

41 ..

42) A patient with psoriasis is prescribed photochemotherapy treatments. What should the nurse teach the patient about future health risks caused by this treatment? Select all that apply. 1. It can accelerate aging. 2. It can exacerbate psoriasis. 3. It can alter immune functions. 4. It can induce cataract development. 5. It can increase the risk of melanoma. Answer: 1, 3, 4, 5 Explanation: 1. Photochemotherapy can accelerate aging of exposed skin. 2. Photochemotherapy has had a high success rate in achieving remission of psoriasis. 3. Photochemotherapy can alter immune function. 4. Photochemotherapy can induce cataract development. 5. Photochemotherapy can increase the risk of melanoma. Page Ref: 475 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 16.1 Describe the pathophysiology and manifestations of common skin problems and lesions, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

42 ..

43) A patient with a skin infection is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). What medication should the nurse expect to be prescribed for this patient? Select all that apply. 1. Penicillin (Pen-V-K) 2. Clindamycin (Cleocin) 3. Minocycline (Minocin) 4. Doxycycline (Vibramycin) 5. Trimethoprim-sulfamethoxazole (Bactrim) Answer: 2, 3, 4, 5 Explanation: 1. Penicillin (Pen-V-K) is not used to treat MRSA infections. 2. MRSA infections may be treated with antimicrobial therapy, including clindamycin (Cleocin). 3. MRSA infections may be treated with antimicrobial therapy, including minocycline (Minocin). 4. MRSA infections may be treated with antimicrobial therapy, including doxycycline (Vibramycin). 5. MRSA infections may be treated with antimicrobial therapy, including trimethoprimsulfamethoxazole (Bactrim). Page Ref: 479 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.2 Describe the pathophysiology and manifestations of infections and infestations of the skin, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

43 ..

44) A patient who was stranded during a snowstorm is admitted for frostbite of the fingers and toes. Which action should the nurse expect to perform for this patient? Select all that apply. 1. Elevate the feet and hands. 2. Provide pain medication as prescribed. 3. Apply elastic compression bandages to the feet and hands. 4. Massage the fingers and toes for 10 minutes after warming. 5. Warm the digits with circulating water for 20 to 30 minutes. Answer: 1, 2, 5 Explanation: 1. After rewarming the affected parts, they should be elevated. 2. Pain medications are provided as prescribed. 3. Elastic compression bandages are not used in the treatment of frostbite. 4. The affected areas should not be massaged. 5. Rapidly rewarm affected areas in circulating warm water, 40° to 40.5°C (104° to 105°F) for 20 to 30 minutes. Page Ref: 509 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 16.6 Describe the pathophysiology and manifestations of skin trauma, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

44 ..

45) During a health assessment a patient reports a family member having a severe skin reaction after receiving an antibiotic that required care in a burn unit for several weeks. Which additional risk factors for Stevens-Johnson syndrome should the nurse assess this patient? Select all that apply. 1. Nation of origin 2. Previous organ transplantation 3. History of an autoimmune disease 4. Medications prescribed for fluid balance 5. History of human immunodeficiency virus (HIV) Answer: 1, 2, 3, 5 Explanation: 1. Persons of Chinese, Southeast Asian, or Indian descent are more likely to carry the gene for Stevens-Johnson syndrome. 2. Risk factors for Stevens-Johnson syndrome include an immune system abnormality related to organ transplantation. 3. Risk factors for Stevens-Johnson syndrome include an immune system abnormality related to an autoimmune disease. 4. Medications specific for fluid balance are not identified as a risk factor for Stevens-Johnson syndrome. 5. Risk factors for Stevens-Johnson syndrome include an immune system abnormality related to HIV. Page Ref: 492 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4 Describe the risk factors for and pathophysiology and manifestations of acute skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with integumentary disorders.

45 ..

46) The nurse is collecting data to be used to complete the SCORTEN scale for a patient with Stevens-Johnson syndrome. Which information should the nurse have prepared to calculate the score for this patient? Select all that apply. 1. Patient age 2. Serum urea level 3. Current heart rate 4. Oxygen saturation 5. Serum glucose level Answer: 1, 2, 3, 5 Explanation: 1. The SCORTEN scale can provide a prognostic indicator of survival in severe cases of Stevens-Johnson syndrome. One indicator is age. Those under the age of 40 have a better prognosis. 2. The SCORTEN scale can provide a prognostic indicator of survival in severe cases of StevensJohnson syndrome. One indicator is serum urea level. Levels under 28 mg/dL have a better prognosis. 3. The SCORTEN scale can provide a prognostic indicator of survival in severe cases of StevensJohnson syndrome. One indicator is heart rate. A rate under 120 beats/minute will have a better prognosis. 4. Oxygen saturation is not an indicator measured on the SCORTEN scale. 5. The SCORTEN scale can provide a prognostic indicator of survival in severe cases of StevensJohnson syndrome. One indicator is serum glucose. Levels under 252 mg/dL have a better prognosis. Page Ref: 492 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 16.4 Describe the risk factors for and pathophysiology and manifestations of acute skin disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with integumentary disorders.

46 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 17 Nursing Care of Patients with Burns 1) A patient receives a chemical burn from contact with lye. Which information should guide the planning of care for this patient? Select all that apply. 1. This is an alkali burn. 2. This type of burn tends to be deeper. 3. This is an acid burn. 4. This type of burn is easier to neutralize. 5. This type of burn tends to be more superficial. Answer: 1, 2 Explanation: 1. This is an alkali burn. 2. This is an alkali burn, which tends to penetrate more deeply. 3. This is not an acid burn. 4. This type of burn is more difficult to neutralize. 5. This type of burn tends to have a deeper penetration. Page Ref: 520 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

1 ..

2) A patient receives an electrical burn. What assessment question should the nurse ask to determine the severity of the burn injury? Select all that apply. 1. What type of current was involved? 2. How long was the patient in contact with the current? 3. How much voltage was involved? 4. Where was the patient when the burn occurred? 5. What was the point of contact with the current? Answer: 1, 2, 3 Explanation: 1. The severity of electrical burns depends on the type of current. 2. The severity of electrical burns depends on the duration of the current. 3. The severity of electrical burns depends on the amount of voltage. 4. Location is not important in determining possible severity. 5. Point of contact is not important in determining possible severity. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

2 ..

3) A patient gets struck by lightning during a thunderstorm on a golf course. What is the first action that should occur in this patient's care? 1. Check breathing and circulation. 2. Look for entrance and exit wounds. 3. Cover the victim to prevent heat loss. 4. Move the victim indoors to a dry place. Answer: 1 Explanation: 1. Cardiopulmonary arrest is the most common cause of death from lightning. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. 2. This is a secondary action. 3. This is a secondary action. 4. This is a secondary action. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

3 ..

4) The nurse is teaching a class of older adults at a senior center about household cleaning agents that may cause burns. Which agents should be included in this discussion? Select all that apply. 1. Drain cleaners 2. Household ammonia 3. Oven cleaner 4. Toiler bowl cleaner 5. Lemon oil furniture polish Answer: 1, 2, 3, 4 Explanation: 1. Drain cleaners are chemical agents that can cause burns. 2. Household ammonia is a chemical agent that can cause burns. 3. Oven cleaners are chemical agents that can cause burns. 4. Toilet bowl cleaners are chemical agents that can cause burns. 5. Lemon oil furniture polish is not identified as a product that can cause chemical burns. Page Ref: 520 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

4 ..

5) A patient has a burn that is pale, waxy, and with large flat blisters. What should the nurse respond when asked about the severity and healing time of the injury? 1. The wound is a deep partial-thickness burn and will take more than 3 weeks to heal. 2. The wound is a superficial partial-thickness burn and could take up to 2 weeks to heal. 3. The wound is a superficial burn and will take up to 3 weeks to heal. 4. The wound is a full-thickness burn and will take 1 to 2 weeks to heal. Answer: 1 Explanation: 1. The patient has a deep partial-thickness burn that often takes more than 3 weeks to heal. 2. The wound is deeper than a superficial partial-thickness burn and will take more than 2 weeks to heal. 3. A superficial burn is pink to bright red, with a healing time of 3 to 6 days. 4. A full-thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Page Ref: 522 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

5 ..

6) The nurse is assessing a patient's burns. What information should the nurse assess to classify this injury? Select all that apply. 1. Depth of the burn 2. Extent of burns on the body 3. Causative agent and duration of exposure 4. Location of burns on the body 5. Time that the burns occurred Answer: 1, 2, 3, 4 Explanation: 1. The depth of the burn (layers of underlying tissue affected) is used in determining the amount of tissue damage and classification of the burn. Burn depth results from a combination of the temperature of the burning agent and the length of contact. 2. The extent of the burn (percentage of body surface area involved) is used in determining the amount of tissue damage and classification of the burn. 3. The causative agent is especially important with burns caused by chemicals such as strong acids or alkaline agents. 4. The location of the burns on the body is one of the important determinants of classification. For example, burns of the face and hands are always considered major burns. 5. Time of occurrence of the burn is not necessary for classification. Page Ref: 521-524 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

6 ..

7) A patient has a scald burn on the arm that is bright red, moist, and has several blisters. How should this burn be classified? Select all that apply. 1. Superficial partial-thickness burn 2. Thermal burn 3. Superficial burn 4. Deep partial-thickness burn 5. Full-thickness burn Answer: 1, 2 Explanation: 1. Superficial partial-thickness burns are often bright red, with a moist, glistening appearance and blister formation. 2. Thermal burns result from exposure to dry or moist heat. 3. A superficial burn is pink to bright red, with possible slight edema over the area. 4. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. 5. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or nonblanching red, with a dry, leathery, firm wound surface. Page Ref: 521 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

7 ..

8) A patient has the following burn injuries: a blistered and reddened anterior trunk, reddened lower back, and pale, waxy anterior right arm. Calculate the extent of the burn injury (TBSA) using the rule of nines. ________% Record your answer rounding to the nearest whole number. Answer: 23 Explanation: The anterior trunk has superficial partial-thickness burns and is calculated as 18% of TBSA. The arm has a deep partial-thickness burn and is calculated as 4.5%. The burn on the lower back is superficial and is not calculated in TBSA. The total is 22.5%, rounded to 23%. Page Ref: 523-524 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

8 ..

9) A patient has partial-thickness burns on both lower legs, over 20% of the total body surface area. How should the nurse classify this burn? 1. Moderate burn injury 2. Minor burn injury 3. Major burn injury 4. Severe burn injury Answer: 1 Explanation: 1. A moderate burn injury is a partial-thickness burn involving 15%-25% of total body surface area in adults. 2. A minor burn injury is a partial-thickness burn involving less than 15% of total body surface area (TBSA) in adults. 3. A major burn injury is a partial-thickness burn involving more than 25% of total body surface area (TBSA) in adults 4. Severe is not a term used in burn injury classifications. Page Ref: 523 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

9 ..

10) A patient has sustained a partial-thickness burn of 28% of total body surface area (TBSA) and full-thickness burn of 30% or greater of TBSA. How should the nurse classify this burn injury? 1. Major 2. Moderate 3. Minor 4. Superficial Answer: 1 Explanation: 1. Partial-thickness burn injuries of greater than 25% of TBSA in adults and fullthickness injuries 10% or greater of TBSA are considered major burn injuries. 2. Moderate burn injuries comprise partial-thickness burns of 15%-25% of TBSA in adults and full-thickness injuries greater than 10% of TBSA not involving ears, eyes, face, hands, feet, and perineum. 3. Minor burn injuries comprise partial-thickness burns of less than 15% of TBSA in adults and full-thickness injuries less than 2% of TBSA not involving ears, eyes, face, hands, feet, and perineum. 4. First-degree (superficial) burns affect only the epidermis, or outer layer of skin. The burn site is red, painful, dry, and with no blisters. Mild sunburn is an example. Page Ref: 523 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

10 ..

11) An older patient is sunburned over much of the body. What self-care technique is MOST important for the nurse to emphasize to this patient? 1. Increasing fluid intake 2. Applying mild lotions 3. Taking mild analgesics 4. Maintaining warmth Answer: 1 Explanation: 1. Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. 2. Applying lotion may help alleviate the manifestation of skin redness from sunburn, but another self-care technique is more critical. 3. Taking mild analgesics may help alleviate the manifestations of pain and headache from sunburn, but another self-care technique is more critical. 4. Maintaining warmth may help alleviate the manifestation of chills from sunburn, but another self-care technique is more critical. Page Ref: 525-526 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment/Teaching/Learning Learning Outcome: 17.4 Describe the pathophysiology and manifestations of minor burns of the skin, and outline the interprofessional care and nursing care of patients with minor burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

11 ..

12) A patient was treated for a scald burn that caused a superficial burn over one hand and a superficial partial-thickness burn on several fingers. What should be included in this patient's teaching? Select all that apply. 1. Report any fever to the healthcare provider. 2. Report any purulent drainage to the healthcare provider. 3. Use only sterile dressings on the fingers. 4. Cleanse the areas every hour with alcohol to prevent infection. 5. Apply a topical antimicrobial agent as instructed. Answer: 1, 2, 3, 5 Explanation: 1. Fever indicates an infection and should be reported to the healthcare provider. 2. Purulent drainage indicates an infection and should be reported to the healthcare provider. 3. Sterile dressings should be used on the superficial partial-thickness burns where the skin is not intact. 4. Daily cleansing is sufficient, with only soap and water, not alcohol. 5. Topical agents may be prescribed by the healthcare provider, and the patient should follow directions for applying to help prevent infection. Page Ref: 525-526 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.4 Describe the pathophysiology and manifestations of minor burns of the skin, and outline the interprofessional care and nursing care of patients with minor burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

12 ..

13) A patient with severe burns to the torso and upper extremities has edema around the burned areas. How should the nurse describe the underlying cause for this assessment finding? 1. Inability of the damaged capillaries to maintain fluids in the cell walls 2. Reduced vascular permeability in the burned area 3. Decreased osmotic pressure in the burned tissue 4. Increased fluids in the extracellular compartment Answer: 1 Explanation: 1. Burn shock occurs during the first 24-36 hours after the injury. During this period, there is an increase in microvascular permeability at the burn site. The osmotic pressure is increased, causing fluid accumulation. 2. There is an increase in microvascular permeability at the burn site. 3. The osmotic pressure is increased, causing fluid accumulation. 4. There is a reduction of fluids in the extracellular body compartments. Page Ref: 527 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

13 ..

14) A patient receiving treatment for severe burns over more than half the body has an indwelling urinary catheter. When evaluating the patient's intake and output, what should the nurse take into consideration? 1. Urine output will be reduced in the first 24-48 hours and will then increase. 2. Urine output will be greatest in the first 24 hours after the burn injury. 3. Urine output will be reduced during the first 8 hours and will then increase as diuresis begins. 4. Urine output will be elevated due to the amount of intravenous fluids administered during the initial phases of treatment. Answer: 1 Explanation: 1. Urine output is reduced in the initial phases as the body manages the insult caused by the injury and fluids are drawn into the interstitial spaces. 2. Urine output is not greatest initially. 3. After the shock period passes, the patient will enter a period of diuresis, which begins between 24 and 36 hours after the burn injury. 4. Urine output will not be elevated initially. Page Ref: 81-82 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

14 ..

15) The nurse is reviewing the results of laboratory tests to assess the renal status of a patient who experienced a major burn event on 45% of the body 24 hours ago. Which result should the nurse expect for this patient? Select all that apply. 1. Glomerular filtration rate (GFR) reduced 2. Specific gravity elevated 3. Creatinine clearance reduced 4. BUN reduced 5. Uric acid decreased Answer: 1, 2 Explanation: 1. During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in a reduction in filtration rate. 2. During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in an increase in specific gravity. 3. During this period, creatinine levels are increased. 4. During this period, BUN levels increase. 5. During this period, uric acid is increased. Page Ref: 529, 532 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.

15 ..

16) The nurse is evaluating laboratory values for a patient with a burn injury. What results should the nurse expect for this patient? 1. Decreased hemoglobin and elevated hematocrit levels 2. Elevated hemoglobin and elevated hematocrit levels 3. Elevated hemoglobin and decreased hematocrit levels 4. Decreased hemoglobin and decreased hematocrit levels Answer: 1 Explanation: 1. Hemoglobin levels are reduced in response to the hemolysis of red blood cells. Hematocrit levels are elevated secondary to hemoconcentration and fluid shifts from the intravascular compartment. 2. Hemoglobin levels are not elevated. 3. Hemoglobin levels are not elevated, and hematocrit levels are not decreased. 4. Hematocrit levels are not decreased. Page Ref: 532 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.

16 ..

17) When monitoring the vital signs of a patient who has sustained a major burn injury, the nurse assesses a heart rate of 112. What should the nurse determine about this finding? 1. This heart rate is normal for the patient's post-burn injury condition. 2. The patient is demonstrating manifestations consistent with the onset of an infection. 3. The patient is demonstrating manifestations consistent with an electrolyte imbalance. 4. The patient is demonstrating manifestations consistent with renal failure. Answer: 1 Explanation: 1. The heart rate in a burn-injured patient is not considered tachycardia until it reaches 120 beats per minute. 2. A heart rate of 112 in this patient does not indicate an infection. 3. A heart rate of 112 in this patient does not indicate an electrolyte imbalance. 4. A heart rate of 112 in this patient does not indicate renal failure. Page Ref: 540 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.

17 ..

18) A patient has sustained a burn injury. Which nursing intervention is of the highest priority at this time? 1. Determine the type of burn injury 2. Determine the types of home remedies attempted prior to the patient's coming to the hospital 3. Assess past medical history 4. Measure body weight Answer: 1 Explanation: 1. Determining the type of burn is the first step. The type of burn injury determines which nursing measures take priority. 2. The use of home remedies must be assessed, but it is not the highest priority. 3. Determining the past medical history is important, but it is not the highest priority. 4. The body weight must be measured, but it is not the highest priority. Page Ref: 520 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

18 ..

19) A patient is scheduled for surgery to graft a burn injury on the arm. Which statement should the nurse include when instructing the patient about the procedure? 1. "You will begin to perform exercises to promote flexibility and reduce contractures after 5 days." 2. "You will need to report any itching, as it might signal infection." 3. "Performing the procedure near the end of the hospitalization will reduce the incidence of infection and improve the chances of success." 4. "The procedure will be performed in your room." Answer: 1 Explanation: 1. The patient will begin to perform range-of-motion exercises after 5 days. 2. Itching is not a symptom of infection but an anticipated sign of cellular growth. 3. The ideal time to perform the procedure is early in the treatment of the burn injury. 4. The procedure is performed in a surgical suite. Page Ref: 536 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

19 ..

20) A patient recovering from a major burn injury is complaining of pain. Which medication should the nurse expect to be prescribed for this patient? 1. Morphine 4 mg IV every 5 minutes 2. Morphine 10 mg IM ever 3-4 hours 3. Meperidine 75 mg IM every 3-4 hours 4. Meperidine 50 mg PO every 3-4 hours Answer: 1 Explanation: 1. Morphine is preferred over meperidine for the patient with a burn injury. The typical dose of morphine is 3-5 mg every 5-10 minutes for an adult. The intravenous route is preferred over the oral and intramuscular routes. 2. Morphine is the drug of choice, but the preferred dose and route are different. 3. Meperidine is not the drug of choice for the patient with a burn injury. 4. Meperidine is not the drug of choice for the patient with a burn injury. Page Ref: 533 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

20 ..

21) A patient with a burn injury is prescribed silver nitrate. Which nursing intervention should be included in the plan of care for this patient? Select all that apply. 1. Monitor daily weight. 2. Monitor serum sodium levels. 3. Prepare to change the dressings every 2 hours. 4. Report black skin discolorations. 5. Saturate the dressings every 2 hours with a 0.5% aqueous solution of silver nitrate. Answer: 1, 2, 5 Explanation: 1. Silver nitrate can cause hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by daily weights. 2. Hyponatremia and hypochloremic alkalosis are common findings in patients treated with silver nitrate, so serum sodium and chloride should be monitored. 3. The dressings should be changed twice daily. 4. Black discolorations of the skin are anticipated in patients using silver nitrate and do not indicate a complication of therapy. 5. Silver nitrate in a 0.5% solution in distilled water should be applied to the dressings every 2 hours. Page Ref: 534 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

21 ..

22) The nurse is evaluating the adequacy of a burn-injured patient's nutritional intake. Which laboratory value indicates the need to adjust the patient's nutritional program? 1. Glycosuria 2. Creatine phosphokinase (CPK) 3. BUN levels 4. Hemoglobin Answer: 1 Explanation: 1. Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient's nutritional plan. 2. Creatine phosphokinase is used to identify the presence of muscle injuries. 3. BUN levels are used to evaluate kidney function. 4. Hemoglobin levels fluctuate with the stages of the burn injury, depending on the fluid status. Page Ref: 532 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.

22 ..

23) A patient is beginning the acute phase of burn treatment. What should the nurse anticipate as priorities for this patient's care? Select all that apply. 1. Wound care 2. Nutritional therapy 3. Infection control 4. Graft procedures 5. Home maintenance management Answer: 1, 2, 3 Explanation: 1. During the acute stage, wound care management is initiated. 2. During the acute stage, nutritional therapies are initiated. 3. During the acute stage, measures to control infectious processes are initiated. 4. Graft procedures occur later in the healing process. 5. Home maintenance management is assessed during the rehabilitative stage, not the acute stage. Page Ref: 539, 541 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

23 ..

24) A patient is admitted to the emergency department with deep partial-thickness burns over 35% of the body. What IV solution will be started initially? 1. Warmed lactated Ringer's solution 2. Dextrose 5% with saline solution 3. Dextrose 5% with water 4. Normal saline solution Answer: 1 Explanation: 1. Lactated Ringer's solution is the IV solution of choice because it most closely approximates the body's extracellular fluid composition. It is warmed to prevent hypothermia. 2. Dextrose 5% with saline is not the solution of choice. 3. Dextrose 5% with water is not the solution of choice. 4. Normal saline is not the solution of choice. Page Ref: 531 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

24 ..

25) Using the Consensus formula, calculate the amount of intravenous solution that will be administered in the first 8 hours for a burn patient with 40% TBSA, weight of 52 kg, and prescribed 2 mL/kg. ________ mL Record your answer rounding to the nearest whole number. Answer: 2080 Explanation: The Consensus formula is 2 mL × total kg of body weight × % TBSA. In this situation, 2 mL × 52 kg × 40 = 4160 mL. One-half is given over the first 8 hours, or 2080 mL. Page Ref: 531 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

25 ..

26) The family of a patient with third-degree burns wants to know why "the scabs are being cut off" the patient's leg. What is the most appropriate response by the nurse? 1. "The scabs are really old burned tissue and need to be removed to promote healing." 2. "I'll ask the doctor to come and talk with you about the treatment plan." 3. "The patient asked for the scabs to be removed." 4. "The scabs are removed to check for blood flow to the burned area." Answer: 1 Explanation: 1. The patient's family is describing eschar, which is the hard crust of burned necrotic tissue. Eschar needs to be removed to promote wound healing. 2. Asking the healthcare provider to discuss the treatment plan does not answer the family's question. 3. It is unlikely that the patient requested that the eschar be removed. 4. Scabs are not removed to check for blood flow. Page Ref: 535 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

26 ..

27) A patient with third-degree burns is prescribed gastrointestinal medication. How should the nurse explain the primary action of this medication? 1. It prevents the formation of a Curling ulcer. 2. It treats a preexisting duodenal ulcer. 3. It ensures adequate peristalsis. 4. It has antiemetic properties. Answer: 1 Explanation: 1. Dysfunction of the gastrointestinal system is directly related to the size of the burn wound. This can lead to a cessation of intestinal motility, which causes gastric distention, nausea, vomiting, and hematemesis. Stress ulcers, or Curling ulcers, are acute ulcerations of the stomach or duodenum that form following the burn injury. 2. There is no evidence of a preexisting duodenal ulcer. 3. Although peristalsis is desired, it is not the primary gastrointestinal concern. 4. There is no data presented to indicate the presence of nausea or vomiting. Page Ref: 535 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

27 ..

28) A patient with third-degree burns has a reduction in the serum potassium level. To which event is this laboratory value related? 1. Resolution of burn shock 2. Onset of burn shock 3. Onset of renal failure 4. Onset of liver failure Answer: 1 Explanation: 1. Potassium levels are initially elevated at the onset of burn shock but decrease after burn shock resolves as fluid shifts back to intracellular and intravascular compartments. 2. Potassium levels are initially elevated at the onset of burn shock. 3. Reduced potassium levels are not indicators of the onset of renal failure. 4. Reduced potassium levels are not indicators of the onset of liver failure. Page Ref: 532 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.

28 ..

29) A patient being treated with topical mafenide acetate for third-degree burns is demonstrating facial and neck edema. What does the nurse realize is the most likely reason? 1. The patient is developing hypersensitivity to the medication. 2. The patient is reacting positively to the medication. 3. The patient needs an increase in dosage of the medication. 4. The patient is not responding to the medication. Answer: 1 Explanation: 1. Approximately 3%-5% of patients develop hypersensitivity to mafenide acetate, which can manifest as facial edema. 2. Facial and neck edema is considered an adverse reaction. 3. The information presented is inadequate to assess whether the dosage should be increased. 4. Facial and neck edema is a response to the medication. Page Ref: 534 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

29 ..

30) Following surgical debridement, a patient with third-degree burns does not bleed. What should this outcome suggest to the nurse? 1. The procedure will need to be repeated. 2. The patient will no longer need this procedure. 3. The patient will need to be premedicated prior to the next procedure. 4. The patient should have an escharotomy instead. Answer: 1 Explanation: 1. Surgical debridement is the process of excising the burn wound by removing thin slices of the wound to the level of viable tissue. If bleeding does not occur after the procedure, it will be repeated. 2. The procedure is still necessary. 3. It is an assumption that patients having debridement all require premedication. 4. An escharotomy involves removal of the hardened crust covering the burned area. Page Ref: 536 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

30 ..

31) The nurse applies Elase to a third-degree burn on a patient's left thigh and left forearm. Which type of wound debridement is the nurse using? 1. Enzymatic 2. Mechanical 3. Surgical 4. Topical Answer: 1 Explanation: 1. Enzymatic debridement involves the use of a topical agent to dissolve and remove necrotic tissue. An enzyme such as Elase is applied in a thin layer directly to the wound and covered with one layer of fine mesh gauze. A topical antimicrobial agent is then applied and covered with a bulky wet dressing. 2. Mechanical debridement may be performed by applying and removing gauze dressings, hydrotherapy, irrigation, or using scissors and tweezers. 3. Surgical debridement is the process of excising the wound to the fascia or removing thin slices of the burn to the level of viable tissue. 4. Topical treatments are key in the care of a burn but do not involve debridement. Page Ref: 537 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

31 ..

32) A patient with full thickness burns is being treated with high-volume intravenous fluids and has a urine output of 40 mL per hour. What does the nurse realize about this urine output? 1. It is normal for this patient. 2. It is evidence that the patient is dehydrated. 3. It is evidence that the patient is overhydrated. 4. It indicates pending renal failure. Answer: 1 Explanation: 1. Intake and output measurements indicate the adequacy of fluid resuscitation and should range from 30 to 50 mL per hour in an adult. 2. A urine output of 40 mL/hr does not indicate dehydration. 3. A urine output of 40 mL/hr does not indicate overhydration. 4. A urine output of 40 mL/hr does not indicate pending renal failure. Page Ref: 540 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

32 ..

33) A patient with third-degree burns on the right arm is scheduled for passive range of motion to the extremity every 2 hours. What should the nurse do prior to this exercise session? 1. Medicate the patient for pain. 2. Empty the patient's indwelling catheter collection bag. 3. Change the patient's bed linens. 4. Change the dressing on the burn. Answer: 1 Explanation: 1. The nurse should anticipate the patient's needs for analgesia and administer pain medication to promote the patient's comfort during the exercise session. 2. Arm exercise is not related to the amount of urine in the catheter bag. 3. Linen changes do not impact range-of-motion activities. 4. The dressing is changed according to the healthcare provider's orders or as needed. Page Ref: 540 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

33 ..

34) A patient with third-degree burns to the face learns that there will be extensive scarring once the burn heals. For which patient problem should the nurse plan interventions? 1. Powerlessness 2. Infection 3. Lack of body fluids 4. Changes in airway maintenance Answer: 1 Explanation: 1. The patient has no control over the outcome of healing or scar formation and is likely to feel powerless. The nurse should allow the patient to express these feelings as part of coping with the news of likely scarring on the face. 2. The patient with a third-degree burn is at risk for infection; however, this question is focused on the impact of facial scarring. 3. There is inadequate information to determine the patient's lack of body fluids. 4. There is inadequate information to determine changes in airway maintenance. Page Ref: 542-543 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Ethical Comportment; Examine personal beliefs, values, and biases with regard to respect for persons, human dignity, equality, and justice; explore ideas of nurse caring and compassion | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

34 ..

35) A patient seeks medical attention for a burn that appears moist with blisters. For which type of burn should the nurse plan care for this patient? 1. Superficial 2. Superficial partial-thickness 3. Deep partial-thickness 4. Full thickness Answer: 2 Explanation: 1. A superficial burn would involve only the surface layer of skin. Redness would be expected. 2. Partial-thickness burns can be either superficial or deep. This patient's burn, which appears moist with blisters, is consistent with a superficial partial-thickness burn. 3. Deep partial-thickness burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. 4. Full-thickness burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. Page Ref: 521 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.2 Explain burn classification by depth and extent of injury. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

35 ..

36) A patient reports nausea, vomiting, chills, and a headache after spending the weekend at a seaside resort. On which assessment should the nurse focus? 1. Sleeping pattern 2. Eating pattern 3. Travel issue including time zone changes 4. Time spent in the sun causing a sunburn Answer: 4 Explanation: 1. The patient has not reported concerns that would support issues with sleep pattern. 2. The patient has not reported concerns that would support issues with diet. 3. The patient has not reported concerns that would support issues with travel. 4. Sunburn results from exposure to ultraviolet light. Because the skin remains intact, the manifestations in most cases are mild and are limited to pain, nausea, vomiting, skin redness, chills, and headache. Page Ref: 521 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

36 ..

37) A patient receives a chemical burn to the left side of the face and right wrist. Where does this patient need to be treated? 1. Outpatient ambulatory clinic 2. Emergency department 3. Burn center 4. Healthcare provider's office, and then at home Answer: 3 Explanation: 1. Patients with small or noninvasive burns may be managed at an outpatient clinic. 2. The emergency department is where a burn would be evaluated. 3. Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. 4. The healthcare provider's office can manage mild burns. Page Ref: 530 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

37 ..

38) The nurse notes an area of stasis around a patient's burn. What changes should the nurse expect to assess in this area over the next week? Select all that apply. 1. The area becomes pale. 2. The area develops necrosis. 3. The area blanches on pressure. 4. The area appears like other skin surfaces. 5. The area appears leathery and coagulated. Answer: 1, 2, 4 Explanation: 1. The medial zone of stasis is initially moist, red, and blistered and blanches on pressure. It may become pale on days 3 to 7 postburn due to decreased perfusion or infection. 2. The medial zone of stasis is initially moist, red, and blistered and blanches on pressure. It may become necrotic on days 3 to 7 postburn due to decreased perfusion or infection. 3. The outer zone of hyperemia is unburned tissue and blanches on pressure. 4. The medial zone of stasis is initially moist, red, and blistered and blanches on pressure. It may recover on days 3 to 7 postburn due to decreased perfusion or infection. 5. The inner zone of coagulation immediately appears leathery and coagulated. Page Ref: 527 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with burns.

38 ..

39) A victim of a fire in a clothing shop is complaining of headache and dizziness and has a potentially dangerous heart rhythm. What should the nurse expect to be prescribed for this patient? Select all that apply. 1. Treatment with prednisone 2. Treatment with vancomycin 3. Treatment with hydroxocobalamin 4. Hyperbaric oxygen therapy 5. Pacemaker insertion Answer: 3, 4 Explanation: 1. These manifestations are consistent with those of cyanide poisoning. Cyanide gas is released when plastics, polyurethane, nylon, or silk is burned. Prednisone is not used to treat cyanide poisoning. 2. These manifestations are consistent with those of cyanide poisoning. Cyanide gas is released when plastics, polyurethane, nylon, or silk is burned. Vancomycin is not used to treat cyanide poisoning. 3. Cyanide gas is released when plastics, polyurethane, nylon, or silk is burned. Manifestations of cyanide poisoning include headache, dizziness, and lethal dysrhythmias. Treatment addresses the inability of the body to use oxygen. Hydroxocobalamin (Cyanokit) is a form of vitamin B12 that converts cyanide to a form that can be excreted from the body. 4. Cyanide gas is released when plastics, polyurethane, nylon, or silk is burned. Manifestations of cyanide poisoning include headache, dizziness, and lethal dysrhythmias. Treatment addresses the inability of the body to use oxygen. Hyperbaric oxygen (oxygen delivery in a highpressure chamber) may be used with inhalation of smoke. 5. These manifestations are consistent with those of cyanide poisoning. Cyanide gas is released when plastics, polyurethane, nylon, or silk is burned. Pacemaker insertion is not used to treat cyanide poisoning. Page Ref: 528 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 2. Consider intraprofessional care for patients with burns.

39 ..

40) The nurse is concerned that an older patient is at risk for a burn injury in the home. What should the nurse instruct the patient to do to reduce this risk? Select all that apply. 1. Check routinely for the odor of gas. 2. Suggest that no one smokes in the home. 3. Wear loose-fitting clothing when cooking. 4. Check the smoke detector battery annually. 5. Keep the hot water heater temperature at 120°F. Answer: 1, 2, 5 Explanation: 1. Actions to reduce the risk of a burn injury in the home include checking routinely for the odor of gas. 2. Actions to reduce the risk of a burn injury in the home include encouraging that no one smokes in the home. 3. Actions to reduce the risk of a burn injury in the home include wearing close-fitting, not loose-fitting, clothing when cooking. 4. Actions to reduce the risk of a burn injury in the home include checking the smoke detector battery once a month, not just annually. 5. Actions to reduce the risk of a burn injury in the home include keeping the hot water heater temperature at 120°F. Page Ref: 539 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 17.1 Discuss the types and causative agents of burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

40 ..

41) A patient recovering from a 30% TBSA full-thickness burn has swelling and inflammation of the intact skin around the burn area. What intervention should the nurse implement to reduce this patient's risk of developing a further infection? Select all that apply. 1. Report results of blood cultures. 2. Analyze daily leukocyte counts. 3. Follow strict isolation techniques. 4. Request placement of an indwelling catheter. 5. Request a dietary consult to ensure adequate nutritional intake. Answer: 1, 2, 3, 5 Explanation: 1. Interventions to reduce the risk of infection include reporting results of blood cultures so that antibiotic therapy can be initiated. 2. Interventions to reduce the risk of infection include monitoring leukocyte counts as indicators of immune system function. This laboratory value will increase in the presence of infection. 3. Interventions to reduce the risk of infection include following strict isolation techniques to prevent the development of a nosocomial infection. 4. Interventions to reduce the risk of infection include reducing or eliminating the use of an indwelling catheter because of the high risk of urinary tract infection. 5. Interventions to reduce the risk of infection include discussing the patient's nutritional needs with the dietician. Nutritional support provides the nutrients needed to maintain the body's defense mechanisms. Page Ref: 541 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 17.5 Describe the pathophysiology and manifestations of major burns of the skin, and outline the interprofessional care and nursing care of patients with major burns. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with burns.

41 ..

42) A patient is receiving emergent care for burns over 45% of TBSA. What should the nurse realize is occurring during the inflammation phase of these injuries? Select all that apply. 1. Epithelial cells cover the wound. 2. Granulation tissue begins to form. 3. Fibrin is deposited within the damaged tissue. 4. Aggregation of platelets within the damaged tissue. 5. Hemostasis walls off the wound from systemic circulation. Answer: 3, 4, 5 Explanation: 1. Covering of the wound with epithelial cells occurs during the proliferation phase of wound healing. 2. Formation of granulation tissue occurs during the proliferation phase of wound healing. 3. During the inflammation phase of wound healing, fibrin is deposited within the damaged tissue. 4. During the inflammation phase of wound healing, platelets aggregate within the damaged tissue. 5. During the inflammation phase of wound healing, hemostasis walls off the wound from systemic circulation. Page Ref: 524-525 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.3 Outline the three stages of burn wound healing. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

42 ..

43) A patient who sustained full-thickness burns six months ago is being evaluated for ongoing care needs. Which finding indicates that the patient's wounds are in the remodeling phase of healing? Select all that apply. 1. Scars fading in color 2. Hypertrophic scarring 3. Scattered areas of keloids 4. Granulation tissue is present 5. Burned tissue resembles neighboring tissue Answer: 2, 3 Explanation: 1. The scars would fade in color if the patient experienced a minor burn. 2. A hypertrophic scar is an overgrowth of dermal tissue that remains within the boundaries of the wound which can occur after a major burn injury. 3. A keloid is a scar that extends beyond the boundaries of the original wound. This can occur after a major burn injury. 4. Granulation tissue occurs during the proliferation phase of wound healing. 5. In normal healing following a minor burn injury, the newly formed skin closely resembles its neighboring tissue. Page Ref: 525 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 17.3 Outline the three stages of burn wound healing. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with burns.

43 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 18 Assessing the Endocrine System 1) The nurse is assessing a patient diagnosed with hypothyroidism. Which health assessment interview question should the nurse ask this patient? 1. "Is your skin feeling rough and dry?" 2. "Is your skin smooth or flushed?" 3. "Does your skin feel clammy?" 4. "Do you have brown, shiny patches on the lower extremities?" Answer: 1 Explanation: 1. The patient experiencing hypothyroidism has rough, dry skin. 2. Smooth, flushed skin is associated with hyperthyroidism. 3. Cool, clammy skin is found in patients with low blood sugar. 4. Brown, shiny patches on the lower extremities are associated with poor circulation. Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

1 ..

2) When measuring the blood pressure of a patient with hypoparathyroidism, the nurse notes spasms of the patient's hand. How should the nurse document this finding? 1. Trousseau sign 2. Chvostek sign 3. Turner sign 4. Cullen sign Answer: 1 Explanation: 1. Trousseau sign is elicited by placing a blood pressure cuff on the patient's arm; when the cuff is inflated, the patient experiences carpal spasms of the hand. 2. Chvostek sign is elicited by tapping on the face in front of the ear and observing for contractions of the facial muscle. 3. Turner sign is observed on a patient's abdomen and flank and associated with intra- or retroperitoneal bleeding. 4. Cullen signs is observed on a patient's abdomen and flank and associated with intra- or retroperitoneal bleeding Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

2 ..

3) A patient has a positive Trousseau sign. For which health problem should the nurse plan care for this patient? 1. Pain 2. Excessive fluid 3. Difficulty breathing 4. Reduced blood flow Answer: 1 Explanation: 1. A positive Trousseau sign causes painful carpal spasms due to decreased calcium. The patient will be experiencing pain. 2. A positive Trousseau sign is not associated with fluid volume. 3. A positive Trousseau sign is not associated with respiratory function. 4. A positive Trousseau sign is not associated with perfusion or blood flow. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

3 ..

4) During an endocrine assessment, the nurse asks a patient about changes in weight. For which organ is the nurse assessing function in the patient? Select all that apply. 1. Adrenal 2. Thyroid 3. Pituitary 4. Parathyroid 5. Gonads Answer: 1, 2, 3 Explanation: 1. Disorders of the adrenal glands can result in weight changes by altering fluid balance. 2. Disorders of the thyroid gland can result in weight changes in patients with disorders of these glands. The patient might gain weight with hypothyroidism and lose weight with hyperthyroidism. 3. Disorders of the pituitary gland can result in weight changes in patients with disorders of these glands. The patient might gain weight as the pituitary gland controls antidiuretic hormone, which influences the renal tubules to absorb water. 4. The parathyroid gland regulates calcium and phosphorous. 5. The gonads influence estrogen and androgens. Page Ref: 551-552 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

4 ..

5) The nurse is assessing a patient with a pituitary disorder. Which finding should the nurse expect to assess in this patient? 1. Enlargement of the hands and feet 2. Thin, soft hair 3. Excessive growth of facial hair 4. Purple striae over the trunk Answer: 1 Explanation: 1. In a patient experiencing a pituitary disorder such as acromegaly, enlargement of the hands and feet may be observed. 2. Thin, soft hair occurs in hyperthyroidism. 3. Hirsutism is associated with Cushing disease, an adrenal disorder. 4. Purple striae are associated with Cushing disease, an adrenal disorder. Page Ref: 105 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

5 ..

6) A patient is demonstrating signs of exophthalmos. What additional finding should the nurse expect to assess in this patient? 1. Enlarged thyroid gland 2. Dry, thick nails 3. Dry skin 4. Decreased reflexes Answer: 1 Explanation: 1. Exophthalmos is a clinical manifestation associated with hyperthyroidism. 2. Dry, thick nails are associated with hypothyroidism. 3. Dry skin is associated with hypothyroidism. 4. Decreased reflexes are associated with hypothyroidism. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

6 ..

7) The nurse is reviewing data collected during a patient's health history. What information would indicate a disorder of the pituitary gland? 1. Dwarfism 2. Carpal spasms 3. Enlarged thyroid nodule 4. Hyperpigmentation of the skin Answer: 1 Explanation: 1. Dwarfism results from insufficient growth hormone produced by the pituitary gland. 2. Carpal spasms can indicate a parathyroid gland disorder. 3. An enlarged thyroid nodule could be associated with a thyroid malignancy. 4. Hyperpigmentation of the skin might be associated with an adrenal disorder such as Addison disease or Cushing syndrome. Page Ref: 555 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

7 ..

8) The nurse is caring for a patient with Graves disease. On which laboratory value should the nurse focus for this patient? 1. Thyroid antibodies 2. Urine-specific gravity 3. Cortisol 4. Calcium Answer: 1 Explanation: 1. Thyroid antibodies (TA) is a blood test that is used to identify thyroid immune disease such as Graves disease. 2. Urine-specific gravity would be measured to provide information about the posterior pituitary. 3. The adrenal gland produces cortisol. 4. The parathyroid gland regulates calcium and phosphorous. Page Ref: 557 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

8 ..

9) The nurse is conducting a physical assessment with a patient. Which assessment technique should the nurse use to assess the patient's thyroid gland? 1. Stand behind the patient and palpate the thyroid. 2. Stand in front of the patient and palpate the thyroid. 3. Place the patient supine and palpate one side of the neck at a time. 4. Have the patient flex the neck forward and palpate the thyroid. Answer: 1 Explanation: 1. The thyroid is palpated by standing behind the patient and placing the fingers on each side of the trachea below the thyroid, and asking the patient to swallow to palpate the right lobe. Repeat the procedure, tilting the neck to the left. 2. The thyroid gland is not palpated by standing in front of the patient. 3. Placing the patient supine would not permit the nurse to have full access to the neck. 4. Flexing the neck forward could occlude the airway if a mass were present. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

9 ..

10) The nurse is beginning the assessment of a patient with an endocrine disorder. What should the nurse include in this assessment? Select all that apply. 1. Height and weight 2. Skin, hair, and nails 3. Deep tendon reflexes 4. Musculoskeletal system 5. Respiratory system Answer: 1, 2, 3, 4 Explanation: 1. When assessing a patient's endocrine system, the nurse should include measuring height and weight. 2. When assessing a patient's endocrine system, the nurse should include evaluating skin, hair, and nails. 3. When assessing a patient's endocrine system, the nurse should include evaluating reflexes. 4. When assessing a patient's endocrine system, the nurse should include evaluating the musculoskeletal system. 5. The respiratory system does not influence the endocrine system. Page Ref: 554-555 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

10 ..

11) The nurse is assessing an older patient with type 2 diabetes mellitus. What age-related endocrine change should the nurse expect in this patient? 1. Decreased sensitivity to insulin 2. More rapid insulin release 3. Intolerance of fatty foods 4. Lower and prolonged blood glucose levels Answer: 1 Explanation: 1. Decreased sensitivity to insulin and delayed and decreased insulin release are seen in the older patient diagnosed with type 2 diabetes. 2. Delayed and decreased insulin release are seen in the older patient diagnosed with type 2 diabetes. 3. Intolerance of fatty foods occurs in older adults but is not specific to the older patient with type 2 diabetes. 4. Blood glucose levels are higher and prolonged in the older patient with diabetes. Page Ref: 561 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3 Differentiate considerations for assessing the endocrine system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

11 ..

12) A patient is having a 17-keosteroid test performed. What statement by the patient indicates that teaching about this test has been effective? 1. "I will store the specimen container in the refrigerator." 2. "I shouldn't eat or drink anything before this test." 3. "I know this test will be helpful in diagnosing my thyroid problem." 4. "I will arrive early to have my blood drawn." Answer: 1 Explanation: 1. The 17-ketosteroid test is a 24-hour collection of urine to evaluate adrenal cortex function. The patient is instructed to collect urine in a container in preservative and store it in the refrigerator. 2. There are no food or fluid restrictions. 3. The 17-ketosteroid test is a 24-hour collection of urine to evaluate adrenal cortex function. 4. The test does not include having blood drawn. Page Ref: 559 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the endocrine system.

12 ..

13) The nurse is conducting a health assessment interview with a patient. What should the nurse include when assessing the patient's endocrine system? Select all that apply. 1. Occupation 2. Use of alcohol, drugs, and tobacco 3. Lifestyle 4. Exercise and sleep patterns 5. Alterations in bowel habits Answer: 1, 2, 3, 4 Explanation: 1. During assessment of the endocrine system, the nurse should ascertain data about occupation. 2. During assessment of the endocrine system, the nurse should ascertain data about substance use. 3. During assessment of the endocrine system, the nurse should ascertain data about lifestyle and personal relationships. 4. During assessment of the endocrine system, the nurse should ascertain data about exercise and sleep patterns. 5. Bowel habits are not influenced by the endocrine system. Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

13 ..

14) The nurse is conducting a health interview with a female patient. What should the nurse ask that focuses on the endocrine system? 1. "Is your menstrual cycle regular?" 2. "Do you have children?" 3. "Are you able to provide for your children?" 4. "How old were you when your menses first began?" Answer: 1 Explanation: 1. The patient who has a change in the menstrual cycle might be experiencing an endocrine disorder such as increased androgen production or decreased estrogen levels. 2. Having children is not a function of the endocrine system. 3. Asking how the patient is able to provide for children provides psychosocial information. 4. Asking when menses first began might provide information about cancer risk but not about endocrine function. Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

14 ..

15) A patient is experiencing severe hypertension. Which endocrine gland should the nurse suspect is causing this patient's health problem? 1. Adrenal 2. Thyroid 3. Parathyroid 4. Gonads Answer: 1 Explanation: 1. The patient with hypertension could be experiencing an adrenal disorder, as the adrenal gland regulates epinephrine and norepinephrine, both of which can influence blood pressure. The adrenal gland also regulates blood pressure by secreting mineralocorticoids and aldosterone. 2. The thyroid regulates metabolism. 3. The parathyroid gland regulates calcium. 4. The gonads secrete the hormones of sexuality. Page Ref: 551 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

15 ..

16) An older adult patient reports ingesting a fat-soluble vitamin every day to boost the endocrine system. For what age-related change does the nurse recognize the patient is addressing by taking this vitamin? 1. The ability to absorb fat-soluble vitamins declines with aging. 2. Lipase production is increased and results in fat intolerance. 3. Older patients have increased resistance to insulin. 4. Indigestion increases with aging due to decreased lipase production. Answer: 1 Explanation: 1. Absorption of fat-soluble vitamins declines with age. 2. Lipase production decreases in the older adult patient, causing reduced fat absorption. 3. Older patients have increased resistance to insulin, but this has no effect on absorption of fat-soluble vitamins. 4. Lipase production decreases in the older adult patient, causing reduced fat absorption. This may result in intolerance to fatty foods and indigestion. Page Ref: 561 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3 Differentiate considerations for assessing the endocrine system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

16 ..

17) The nurse is assessing an older patient for genetic influences on the endocrine system. What should the nurse ask this patient during the assessment? Select all that apply. 1. "Do you have any family members with diabetes mellitus?" 2. "Is there a pattern of obesity in your family?" 3. "Has anyone in your family been diagnosed with Hashimoto disease?" 4. "How do you cope with stress?" 5. "Have you noticed any changes in coloration of your skin?" Answer: 1, 2, 3 Explanation: 1. A family history of diabetes mellitus has a genetic influence on the endocrine system. 2. Obesity has a genetic influence on the endocrine system. 3. Hashimoto disease has a genetic influence on the endocrine system. 4. Questions about the patient's ability to cope with stress are asked to identify possible disorders of endocrine gland function. 5. Questions about changes in skin color are asked to identify possible disorders of endocrine gland function. Page Ref: 554, 561 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3 Differentiate considerations for assessing the endocrine system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

17 ..

18) During a focused endocrine assessment, a patient states that a brother has fragile X syndrome. What should the nurse recall about this health problem? 1. It is an endocrine disorder having a genetic basis. 2. It is not a relevant issue since the patient is female. 3. It is a health condition separate from the endocrine system. 4. It is a blood disorder. Answer: 1 Explanation: 1. Fragile X syndrome involves a gene mutation causing learning disabilities and mental retardation and is considered an endocrine disorder. 2. Males are more severely affected than females, and both sexes can be carriers of the disorder. 3. Fragile X syndrome is considered an endocrine disorder. 4. Fragile X syndrome is not a blood disorder. Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

18 ..

19) A patient is scheduled for surgery to remove a tumor of the anterior pituitary. Which hormone should the nurse expect to be affected by this surgery? Select all that apply. 1. Adrenocorticotropic hormone (ACTH) 2. Thyroid stimulating hormone (TSH) 3. Gonadotropin hormones 4. Prolactin 5. Oxytocin Answer: 1, 2, 3, 4 Explanation: 1. The anterior pituitary produces adrenocorticotropic hormone. 2. The anterior pituitary produces thyroid-stimulating hormone. 3. The anterior pituitary produces the gonadotropin hormones, one of which is folliclestimulating. 4. The anterior pituitary produces the gonadotropin hormones, one of which is prolactin. 5. Oxytocin is produced in the posterior pituitary. Page Ref: 549 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

19 ..

20) While instructing a patient on pain relief, the nurse uses the example of endorphins as endocrine hormones, which act locally at the site of injury. What route of hormone transport is the nurse explaining? 1. Paracrine method 2. Direct release into the bloodstream 3. Neuroendocrine route 4. Nerve cell extension into the posterior pituitary Answer: 1 Explanation: 1. The paracrine method involves diffusion of hormones through interstitial fluids to act locally. Endorphins produce pain relief in this manner. 2. This method does not release hormones directly into the bloodstream. 3. This method is not the neuroendocrine route. 4. This method is not accomplished through nerve cell extension into the posterior pituitary. Page Ref: 552 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

20 ..

21) The nurse is completing an endocrine-focused health assessment interview with an older adult. What finding should the nurse suspect is related to an age-related change in the patient's thyroid function? 1. Inability to tolerate heat and cold 2. Indigestion and intolerance of fatty foods 3. Increased facial hair 4. Enlarged nose, hands, and feet Answer: 1 Explanation: 1. A lowered basal metabolic rate due to decreased thyroid activity in the aging patient may cause intolerance to heat and cold. 2. Decreased production of the pancreatic enzyme lipase results in indigestion and intolerance of fatty foods. 3. Increased facial hair occurs with decreased pituitary function. 4. Enlargement of nose, hands, and feet occurs with decreased pituitary function. Page Ref: 561 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3 Differentiate considerations for assessing the endocrine system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

21 ..

22) The nurse is instructing a patient with low levels of circulating thyroid hormone. Food containing which nutrient should the nurse encourage the patient to increase the consumption? 1. Iodine 2. Calcium 3. Phosphorus 4. Vitamin D Answer: 1 Explanation: 1. Iodine is necessary for adequate thyroid hormone secretion. 2. Calcium does not affect thyroid hormone secretion. 3. Phosphorus does not affect thyroid hormone secretion. 4. Vitamin D does not affect thyroid hormone secretion. Page Ref: 550 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

22 ..

23) The nurse is conducting an interview with an adult female patient. Which question should the nurse ask that focuses on genetic factors that influence the endocrine system? Select all that apply. 1. Did you have any difficulties with your pregnancies? 2. What was the pattern and characteristics of your menstrual cycle? 3. Did you have any problems related to menopause? 4. Have you noticed any changes in your breasts? 5. Have you noticed any changes in the color of your urine or feces? Answer: 1, 2, 3 Explanation: 1. Questions for the female patient that could identify genetic factors affecting the patient would include problems with pregnancy. 2. Questions for the female patient that could identify genetic factors affecting the patient would include problems with menstruation. 3. Questions for the female patient which could identify genetic factors affecting the patient would include problems with menopause. 4. This question does not focus on possible genetic influences on endocrine function. 5. This question does not focus on possible genetic influences on endocrine function. Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

23 ..

24) A patient is demonstrating symptoms of dehydration and excessive urination. Which hormone should the nurse suspect is causing this patient's symptoms? 1. Antidiuretic hormone (ADH) 2. Adrenocorticotropic hormone (ACTH) 3. Follicle-stimulating hormone (FSH) 4. Thyroid-stimulating hormone (TSH) Answer: 1 Explanation: 1. Antidiuretic hormone decreases urine production by causing the renal tubules to reabsorb water from the urine and return it to the circulating blood. This patient is demonstrating excessive urination, which might indicate an alteration in this hormone. 2. Adrenocorticotropic hormone stimulates adrenal function. 3. Follicle-stimulating hormone functions in ovum and sperm formation. 4. Thyroid-stimulating hormone stimulates thyroid function. Page Ref: 550 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

24 ..

25) The nurse suspects that a patient is experiencing a response to stress. By which route should the nurse expect hormone transport to be conducted in this stress response? 1. Neuroendocrine 2. Paracrine 3. Portal 4. Nerve cell extension Answer: 1 Explanation: 1. When a patient is undergoing a stress response, epinephrine is released into the bloodstream by the adrenal medulla, which is an example of the neuroendocrine route of hormone transport. 2. The paracrine route involves endorphins being released into interstitial fluids to act locally in response to inflammation. 3. The portal route involves most endocrine hormones being released into the bloodstream to act on target organs, such as occurs with thyroid hormone and insulin. 4. The hypothalamus releases its hormones directly to target cells in the posterior pituitary by nerve cell extension. Page Ref: 552 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

25 ..

26) The nurse is assessing a patient for Trousseau sign. In which order should the nurse conduct this assessment? Place in order the steps of the process. Choice 1. Inflate the cuff. Choice 2. Wait 2‒5 minutes. Choice 3. Note a point greater than systolic blood pressure. Choice 4. Place a blood pressure cuff above the antecubital space. Choice 5. Observe for carpal spasms in the patient's hands and fingers. Answer: 4, 1, 3, 2, 5 Explanation: Trousseau sign is a test for hypocalcemia with resulting tetany (tonic muscle spasms). It is assessed by placing a blood pressure cuff above the antecubital space, inflating the cuff to a point greater than systolic blood pressure and waiting for 2‒5 minutes to observe for carpal spasms in the patient's hands and fingers. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

26 ..

27) A patient has been experiencing fatigue and prolonged symptoms of a cold that started after beginning a new job and a family member moved in. Which reaction should the nurse suspect is occurring in this patient? 1. An increase in glucocorticoid secretion 2. An increase in epinephrine secretion 3. A drop in mineralocorticoid secretion 4. A reduction in norepinephrine secretion Answer: 1 Explanation: 1. The glucocorticoids include cortisol and cortisone. These hormones affect carbohydrate metabolism and are released in times of stress. An excess of glucocorticoids in the body depresses the inflammatory response and inhibits the effectiveness of the immune system. 2. Alteration in epinephrine would have an influence on cardiovascular function and fluid and electrolyte balance, but would not influence immune response as much as an increase in glucocorticoid secretion. 3. Alteration in mineralocorticoids would have an influence on cardiovascular function and fluid and electrolyte balance, but would not influence immune response as much as an increase in glucocorticoid secretion. 4. Alteration in norepinephrine would have an influence on cardiovascular function and fluid and electrolyte balance, but would not influence immune response as much as an increase in glucocorticoid secretion. Page Ref: 551 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

27 ..

28) A patient who is scheduled to have a hemoglobin A1C level drawn asks about the purpose of the test. How should the nurse respond to this patient? 1. "It's to check for pancreas functioning." 2. "It's a blood test to check for kidney functioning." 3. "It's to check for thyroid functions." 4. "It's a blood test to check for menopausal symptoms." Answer: 1 Explanation: 1. The diagnostic tests of the pancreas are primarily to identify, confirm, and monitor glucose levels in patients with diabetes mellitus. The hemoglobin A1C is one of these tests. 2. Hemoglobin A1C does not measure kidney function. 3. Hemoglobin A1C does not measure thyroid function. 4. Hemoglobin A1C does not measure menopausal symptoms. Page Ref: 560 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the endocrine system.

28 ..

29) The nurse is planning to assess a patient's endocrine system. What should the nurse expect to perform on this patient? 1. Palpation of the thyroid gland 2. Palpation of the pancreas 3. Percussion of the adrenal glands 4. Palpation of the parathyroid glands Answer: 1 Explanation: 1. The only endocrine organ that can be palpated is the thyroid gland. 2. The anatomical location of the pancreas prohibits direct examination by palpation or percussion. 3. The anatomical location of the adrenal glands prohibits direct examination by palpation or percussion. 4. The anatomical location of the parathyroid glands prohibits direct examination by palpation or percussion Page Ref: 554 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the endocrine system.

29 ..

30) During an assessment, the nurse notes that the patient's eyes are extremely wide open and bulging. With which health problem is this finding associated? 1. Hyperthyroidism 2. Diabetes mellitus 3. Hypofunction of the adrenal glands 4. Hypofunction of the anterior pituitary gland Answer: 1 Explanation: 1. Exophthalmos, or protruding eyes, may be seen in hyperthyroidism. 2. This is not a finding that is associated with diabetes mellitus. 3. This is not a finding that is associated with hypofunction of the adrenal glands. 4. This is not a finding that is associated with hypofunction of the pituitary gland. Page Ref: 555 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

30 ..

31) The nurse is assessing a patient. What health problem should the nurse suspect is caused by abnormally high levels of growth hormone in a patient? 1. Acromegaly 2. Dwarfism 3. Hirsutism 4. Gynecomastia Answer: 1 Explanation: 1. Extremely large bones may indicate acromegaly, which is caused by excessive growth hormone. 2. Extremely short stature may indicate dwarfism, which is caused by insufficient growth hormone. 3. Hirsutism, or abnormal hair growth, is associated with adrenal hormone access. 4. Gynecomastia, or development of breast tissue in men, is frequently associated with androgen therapy. Page Ref: 555 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

31 ..

32) A patient is demonstrating symptoms of hypocalcemic tetany. What assessment should the nurse conduct to determine the patient's health problem? 1. Tap a finger in front of the patient's ear at the angle of the jaw. 2. Place a tuning fork over one of the patient's fingers. 3. Measure the patient's blood pressure. 4. Measure capillary blood. Answer: 1 Explanation: 1. The nurse should assess the patient for Chvostek sign by tapping a finger in front of the patient's ear at the angle of the jaw. Decreased calcium levels will cause the patient's lateral facial muscles to contract. This demonstrates tetany. 2. Placing a tuning fork over the patient's finger evaluates the patient's ability to perceive vibrations, but it does not evaluate the muscle response of tetany. 3. Blood pressure measurement may give the nurse valuable information about the patient's fluid and electrolyte status, but it does not evaluate tetany. 4. A capillary blood level for serum calcium would give a measurement, but it does not assess for the clinical symptoms of tetany. Page Ref: 555 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

32 ..

33) An older patient who is seen in the clinic has a palpable thyroid gland. What should the nurse realize this finding indicates? 1. Normal finding in the older patient 2. Onset of hypertension 3. Onset of diabetes mellitus 4. Explanation for a reduced urine output Answer: 1 Explanation: 1. Older patients' thyroid glands can be more fibrotic and nodular as a normal finding. 2. Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of hypertension. 3. Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of diabetes mellitus. 4. Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of reduction in urine output. Page Ref: 561 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.3 Differentiate considerations for assessing the endocrine system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

33 ..

34) A patient being treated with medication for a seizure disorder is scheduled for a serum T3 and T4 level. What results should the nurse expect for these levels? 1. Falsely reduced 2. Falsely elevated 3. Normal 4. Pending parathyroid hormone disease Answer: 1 Explanation: 1. The value of T3 and T4 blood levels might be decreased by certain medications including phenytoin (Dilantin), which is a medication commonly prescribed for seizure disorders. 2. Medication for a seizure disorder will not falsely elevate T3 and T4 blood levels. 3. T3 and T4 levels will not be normal when a patient is taking an antiseizure medication. 4. Measurement of T3 and T4 levels is not indicative of parathyroid disease. Page Ref: 557-558 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the endocrine system.

34 ..

35) A patient has a low cortisol level. With which health problem is this finding associated? 1. Addison disease 2. Hyperthyroidism 3. Cushing syndrome 4. Diabetes mellitus Answer: 1 Explanation: 1. A cortisol level is a serum test done to measure the amount of total cortisol in the serum and evaluate adrenal cortex function. Decreased levels are associated with Addison disease. 2. A cortisol level is a serum test done to measure the amount of total cortisol in the serum and evaluate adrenal cortex function. Decreased levels do not indicate hyperthyroidism. 3. Cushing syndrome would cause an elevated cortisol level. 4. A cortisol level is a serum test done to measure the amount of total cortisol in the serum and evaluate adrenal cortex function. Decreased levels are not associated with diabetes mellitus. Page Ref: 559 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

35 ..

36) A patient is pleased to learn that an oral glucose tolerance test is not needed after having a fasting blood glucose level drawn. What should the nurse explain as the reason for the oral glucose tolerance test to be cancelled? 1. Consistently high fasting blood glucose levels 2. No evidence of type 1 diabetes mellitus 3. Normal renal functioning 4. Normal liver functioning Answer: 1 Explanation: 1. An oral glucose tolerance test is done to diagnose diabetes mellitus if prior fasting blood sugar levels are inconsistent. However, the test will not be done if the patient's fasting blood sugars are consistently high or greater than 200 mg/dL. 2. Cancellation of the test does not indicate absence of evidence of type 1 diabetes. 3. Cancellation of the test does not indicate normal liver function. 4. Cancellation of the test does not indicate normal renal function. Page Ref: 560 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

36 ..

37) The nurse suspects that a patient is experiencing a response caused by the hormones of the adrenal medulla. What did the nurse assess to come to this conclusion? Select all that apply. 1. Heart rate 112 beats per minute 2. Cold extremities 3. Respiratory rate 24 breaths per minute 4. Urine output 10 mL/hr 5. Blood glucose level 142 mg/dL Answer: 1, 2, 3, 5 Explanation: 1. Hormones secreted by the adrenal medulla stimulate the heart. 2. Hormones secreted by the adrenal medulla constrict blood vessels, which could cause cold extremities. 3. Hormones secreted by the adrenal medulla can increase respirations. 4. Hormones secreted by the adrenal medulla do not affect urine output. 5. Hormones secreted by the adrenal medulla increase blood glucose. Page Ref: 551 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

37 ..

38) The nurse is reviewing the function of the pancreas with a patient who is newly diagnosed with diabetes mellitus. When discussing this organ's function, on which cell type should the nurse focus? Select all that apply. 1. F cells 2. Beta cells 3. Delta cells 4. Alpha cells 5. Omega cells Answer: 2, 3, 4 Explanation: 1. F cells secrete pancreatic polypeptide, which is believed to inhibit the exocrine activity of the pancreas and has no impact on the regulation of blood glucose. 2. Beta cells produce insulin, which facilitates the uptake and use of glucose by muscle, liver, and fat cells and prevents an excessive breakdown of glycogen in the liver and muscle. 3. Delta cells secrete somatostatin, which inhibits the secretion of glucagon and insulin by the alpha and beta cells. 4. Alpha cells produce glucagon, which decreases glucose oxidation and promotes an increase in the blood glucose level by signaling the liver to release glucose from glycogen stores. 5. The pancreas does not have omega cells. Page Ref: 551 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 18.1 Describe the anatomy, physiology, and functions of the endocrine glands and hormones, and identify abnormal findings that may indicate impairment of the endocrine system. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

38 ..

39) A patient is scheduled for a water deprivation test. What should the nurse instruct the patient to prepare for this test? Select all that apply. 1. Expect this test to take 16 hours to complete. 2. Abstain from smoking as directed by the healthcare provider. 3. A sedative will be provided prior to the beginning of the test. 4. Do not eat or drink anything as directed by the healthcare provider. 5. Blood and urine samples will be collected every hour during the test. Answer: 2, 4, 5 Explanation: 1. The water deprivation test takes up to 8 hours to complete. 2. For the water deprivation test, the patient should be instructed to not smoke as directed by the healthcare provider. 3. For the water deprivation test, a sedative is not needed. 4. For the water deprivation test, the patient should be instructed not to eat or drink as directed by the healthcare provider. 5. For the water deprivation test, blood samples for osmolality are taken when urine samples are collected each hour. Page Ref: 556 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the endocrine system.

39 ..

40) During a physical assessment the nurse suspects a patient is experiencing hypothyroidism. What skin assessment finding did the nurse use to make this assumption? Select all that apply. 1. Rough, dry skin 2. Smooth, flushed skin 3. Yellowish cast to the skin 4. Areas of hyperpigmentation 5. Purple striae over the abdomen Answer: 1, 3 Explanation: 1. Rough, dry skin is often seen in patients with hypothyroidism. 2. Smooth, flushed skin can be a sign of hyperthyroidism. 3. A yellowish cast to the skin might indicate hypothyroidism. 4. Areas of hyperpigmentation may be seen in patients with Addison disease or Cushing syndrome. 5. Purple striae over the abdomen may be present in patients with Cushing syndrome. Page Ref: 554 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 18.2 Outline the components of the assessment of the endocrine system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the endocrine system collected during assessment.

40 ..

41) The nurse is preparing material to present during a community health fair. Which information about type 2 diabetes mellitus should the nurse include? Select all that apply. 1. Control weight. 2. Choose healthy family meals. 3. Increase amount of exercise. 4. Engage in a walking program. 5. Reduce the intake of saturated fats. Answer: 1, 2, 3 Explanation: 1. One health promotion activity for type 2 diabetes mellitus is to control weight. 2. One health promotion activity for type 2 diabetes mellitus is to choose healthy family meals. 3. One health promotion activity for type 2 diabetes mellitus is to increase the amount of exercise. 4. A walking program would be beneficial for the patient with osteoporosis. 5. Reducing the intake of saturated fats would be appropriate for the patient with hypertension or cardiovascular disease. Page Ref: 562 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 18.4 Summarize topics that nurses teach to promote healthy endocrine function across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

41 ..

42) A public health report was published that identified high exposure to bisphenol A (BPA) in a community. On what should the nurse focus when sharing this information during a community town hall meeting? Select all that apply. 1. Identify food containers with BPA. 2. Avoid using food containers with BPA. 3. Receive a vaccination to prevent BPA toxicity. 4. Have laboratory studies to measure BPA levels. 5. Avoid purchasing food items in containers with BPA. Answer: 1, 2, 5 Explanation: 1. Actions to reduce BPA exposure include identifying food containers with the chemical. 2. Actions to reduce BPA exposure include avoiding the use of food containers with BPA. 3. There is no vaccination to prevent BPA toxicity. 4. Laboratory studies to measure BPA levels are not identified as an appropriate action. 5. Actions to reduce BPA exposure include avoiding the purchase of food items in containers with BPA. Page Ref: 562 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 18.4 Summarize topics that nurses teach to promote healthy endocrine function across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the endocrine system collected during assessment and health promotion activities to support the health of this body system.

42 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 19 Nursing Care of Patients with Endocrine Disorders 1) While assessing a patient with an alteration in thyroid function, the nurse notes smooth, fine hair and warm, dry skin. Which question should the nurse ask this patient? 1. "Have you experienced any recent weight loss?" 2. "Have you been feeling constipated?" 3. "Have you noticed increased bruising?" 4. "Have you noticed a change in your skin color?" Answer: 1 Explanation: 1. The patient with hyperthyroidism can present with dry, warm skin, and the hair may become fine. Weight loss is another symptom of hyperthyroidism. 2. Constipation is a symptom of hypothyroidism or hyperparathyroidism. Dry, warm skin and hair that becomes fine are associated with another disorder. 3. Increased bruising is a sign of Cushing syndrome. Dry, warm skin and hair that becomes fine are associated with another disorder. 4. A change in skin color is a sign of Addison disease. Dry, warm skin and hair that becomes fine are associated with another disorder. Page Ref: 566 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

1 ..

2) The nurse is providing preoperative teaching to a patient scheduled for a subtotal thyroidectomy. What should the nurse include in these instructions? 1. Report sensations of tingling in toes, fingers, or lips. 2. Report signs of constipation. 3. Report the improvement of hoarseness. 4. Take aspirin before the surgery. Answer: 1 Explanation: 1. Hypoparathyroidism may result from manipulation of the parathyroid glands during a subtotal thyroidectomy. The lack of circulating parathyroid hormone (PTH) causes hypocalcemia. Neuromuscular manifestations that result from hypocalcemia include numbness and tingling around the mouth and in the fingertips. 2. Hypoparathyroidism may result from manipulation of the parathyroid glands during a subtotal thyroidectomy. The lack of circulating PTH causes hypocalcemia. Constipation is associated with hypercalcemia, not hypocalcemia. 3. The improvement of hoarseness would be desired. 4. Antiplatelet agents, such as aspirin, should be withheld prior to surgery. Page Ref: 570 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

2 ..

3) The nurse is caring for a patient with elevated serum T3 and T4 levels who receives a new prescription for methimazole (Tapazole). Which patient statement indicates that additional teaching is needed about this medication? 1. "This medication will increase my metabolism." 2. "I must contact my physician if I plan to become pregnant." 3. "It may take several weeks for this medication to take effect." 4. "I may take a beta-blocker along with this medication." Answer: 1 Explanation: 1. Hyperthyroidism is treated by administering methimazole or PTU, medications that reduce TH production, thereby decreasing metabolism. 2. Methimazole crosses the placenta and cannot be taken during pregnancy. 3. Antithyroid medications inhibit thyroid hormone production but have no effect on alreadyproduced and circulating thyroid hormone. It can take several weeks for the patient to experience the effects. 4. To rapidly reduce the cardiovascular symptoms associated with hyperthyroidism, propranolol (Inderal) or esmolol, a rapid-acting parenteral beta-blocker, may be used along with methimazole. Page Ref: 569 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

3 ..

4) The nurse is reviewing postoperative care for a patient scheduled for a thyroidectomy. What information should the nurse include in this teaching? 1. "Avoid the use of iodized salt after your procedure." 2. "Plastic surgery may be required to conceal the surgical scar." 3. "Use iodized salt when preparing foods." 4. "Perform neck flexion and extension exercises twice daily for several weeks postoperatively." Answer: 1 Explanation: 1. The nurse anticipates that the patient who has a thyroidectomy will require a lifelong prescription for a thyroid preparation. Iodized salt and iodine preparations should not be taken with thyroid preparations. 2. Typically the scar fades to a small line, so plastic surgery is not needed. 3. Iodized salt and iodine preparations should not be taken with thyroid preparations. 4. The patient is instructed to support the neck by placing both hands behind the neck when sitting up in bed, while moving about, and while coughing. Neck extension would place stress on the suture line. Page Ref: 576 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

4 ..

5) The nurse is caring for a patient with elevated serum thyroid hormones and new-onset proptosis. Which problem would be a priority for this patient? 1. Change in appearance 2. Altered immunity 3. Weight gain 4. Fluid retention Answer: 1 Explanation: 1. Proptosis changes the appearance of the eyes. The problem that would be a priority for the patient is a change in appearance. 2. Proptosis does not affect immune function. 3. Proptosis is associated with hyperthyroidism. There is a risk that the patient will lose weight. 4. Proptosis does not affect fluid balance. Page Ref: 566 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

5 ..

6) A patient whose thyroid gland produces an insufficient amount of thyroid hormone is concerned about an elevated cholesterol level. What should the nurse explain to this patient? 1. "The thyroid gland malfunction can affect your cholesterol level." 2. "Maybe you don't realize how much fat is in the foods you eat." 3. "Elevated cholesterol is a normal part of aging." 4. "Describe your typical bedtime snack." Answer: 1 Explanation: 1. Deficient amounts of thyroid hormone can cause abnormalities in lipid metabolism, with elevated serum cholesterol and triglyceride levels. As a result, the patient is at increased risk for atherosclerosis and cardiac disorders. 2. The nurse should not make assumptions about the patient's dietary intake. 3. Comments about aging are not therapeutic. 4. Comments about eating at bedtime are not therapeutic. Page Ref: 573 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

6 ..

7) The family of an older patient with hypothyroidism is concerned about the open wounds on the patient's legs and arms. How should the nurse respond to the family's questions about bathing? 1. "Use warm water to bathe the patient." 2. "Make sure bathing occurs daily." 3. "Use firm, consistent strokes when bathing." 4. "Follow the bath with a rubbing-alcohol massage." Answer: 1 Explanation: 1. The patient with hypothyroidism has dry skin and edema, which increase the risk of skin breakdown. Hot water, rough massage, and the use of alcohol-based products increase skin dryness. The patient should only bathe when necessary, with warm, not hot, water. 2. The patient should bathe only when necessary. 3. Gentle motions should be used. 4. Alcohol-free oils and lotions should be used. Page Ref: 577 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

7 ..

8) The nurse is assessing a patient who has an abnormally high level of parathyroid hormone. Which assessment finding would be consistent with this diagnosis? Select all that apply. 1. Muscle atrophy 2. Muscle weakness 3. Diarrhea 4. Weight gain 5. Hypotension Answer: 1, 2 Explanation: 1. Manifestations of hyperparathyroidism are related to hypercalcemia. Elevated calcium levels alter neural and muscular activity, leading to muscle atrophy. 2. Manifestations of hyperparathyroidism are related to hypercalcemia. Elevated calcium levels alter neural and muscular activity, leading to muscle weakness. 3. Diarrhea is not a manifestation of hyperparathyroidism. 4. Weight gain is not a manifestation of hyperparathyroidism. 5. Hypotension is not a manifestation of hyperparathyroidism. Page Ref: 580 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

8 ..

9) The nurse is providing care to a patient with a low level of serum parathyroid hormone. What should the nurse expect to assess in this patient? Select all that apply. 1. Brittle nails 2. Abdominal cramps 3. Hair loss 4. Dysrhythmias 5. Smooth, soft skin Answer: 1, 2, 3, 4 Explanation: 1. Brittle nails is an integumentary manifestation of hypoparathyroidism. 2. Abdominal cramps are a gastrointestinal manifestation of hypoparathyroidism. 3. Hair loss is an integumentary manifestation of hypoparathyroidism. 4. Dysrhythmias are a cardiovascular manifestation of hypoparathyroidism. 5. Smooth, soft skin is not a common finding in the patient with hypoparathyroidism. Page Ref: 580 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

9 ..

10) A patient taking steroids for an autoimmune disorder asks when the weight loss in the legs is going to stop. What should the nurse realize the patient is experiencing? 1. Muscle wasting 2. Poor wound healing 3. Risk for compression fractures 4. Increased susceptibility to infections Answer: 1 Explanation: 1. Long-term use of steroids can place a patient at risk for developing Cushing syndrome. One characteristic of this syndrome is muscle weakness and wasting, particularly in the extremities. 2. Poor wound healing is common in patients who are being treated with steroids. However, this would not manifest as weight loss in the limbs. 3. Risk for compression fractures is common in patients who are being treated with steroids. However, this would not manifest as weight loss in the limbs. 4. Increased susceptibility to infections is common in patients who are being treated with steroids. However, this problem would not manifest as weight loss in the limbs. Page Ref: 581 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

10 ..

11) The nurse is providing care to a patient recovering from a bilateral adrenalectomy. What should the nurse do to assess for the onset of adrenal insufficiency? 1. Monitor strict intake and output. 2. Change the dressing using clean technique. 3. Question the order for cortisol administration. 4. Place the patient on fluid restriction. Answer: 1 Explanation: 1. Removal of an adrenal gland, especially a bilateral adrenalectomy, results in adrenal insufficiency. Addisonian crisis and hypovolemic shock may occur. The nurse should monitor intake and output. 2. While care should be taken during dressing changes to avoid infection, this will not prevent adrenal insufficiency. 3. Cortisol is often given on the day of surgery and in the postoperative period to replenish inadequate hormone levels. 4. Intravenous fluids are administered postoperatively. Page Ref: 586 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

11 ..

12) A patient with Cushing syndrome is concerned about having a head cold every few weeks. What should the nurse do to address this patient's concern? 1. Assess for protein and vitamin intake. 2. Plan for frequent rest periods. 3. Encourage daily weights. 4. Review coping strategies. Answer: 1 Explanation: 1. The patient with Cushing syndrome is at risk for infection due to the overproduction of glucocorticoids. The nurse should assess for protein and vitamins C and A intake which are all needed to support and repair body tissues. 2. Rest periods are recommended in the care of a patient with Cushing but would not address the problem of frequent infections. 3. Daily weights are recommended in the care of a patient with Cushing but would not address the problem of frequent infections. 4. There is no indication of a need to review or change coping strategies. Page Ref: 583 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

12 ..

13) A patient with an adrenal gland alteration asks why the skin appears tan when no time is spent outdoors in the sun. What should the nurse do to address the patient's concern? 1. Ask if the patient is still taking steroids prescribed for another illness. 2. Ask the patient what time of day he is outdoors. 3. Auscultate the patient's lung sounds. 4. Palpate the patient's thyroid gland. Answer: 1 Explanation: 1. Addison disease could develop if a patient abruptly stops taking steroids for a chronic health condition. 2. The patient has already reported that no time is spent outdoors in the sun. 3. Auscultation of lung sounds would not help in determining the cause of this skin change. 4. Palpation of the thyroid gland would not help in determining the cause of this skin change. Page Ref: 584 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

13 ..

14) A patient is experiencing manifestations of Addisonian crisis. What should the nurse expect to provide to this patient? 1. Intravenous fluids 2. Warm blankets 3. Thyroid replacement hormone 4. Blood transfusion Answer: 1 Explanation: 1. The manifestations of Addisonian crisis are high fever, weakness, abdominal pain, severe hypotension, circulatory collapse, shock, and coma. The crisis is treated with rapid intravenous replacement of fluids. 2. The patient in Addisonian crisis may have a high fever, so warm blankets would not promote comfort or therapeutic action. 3. There is no thyroid hormone insufficiency. 4. There are no indications the patient is in need of a blood transfusion. Page Ref: 586 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

14 ..

15) A 35-year-old female patient taking oral contraceptives is prescribed steroid therapy. What is a priority teaching point for this patient? 1. "Consider adding another form of contraception while using both medications." 2. "These medications do not interact. No changes need to be made." 3. "Measure your weight daily." 4. "Avoid the use of salt." Answer: 1 Explanation: 1. Corticosteroids may impair the effectiveness of oral contraceptives. 2. Corticosteroids may impair the effectiveness of oral contraceptives. 3. Daily weights have nothing to do with the interaction of oral contraceptives and steroids. 4. Limiting salt has nothing to do with the interaction of oral contraceptives and steroids. Page Ref: 586 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

15 ..

16) The nurse is reviewing the relationship between thyroid hormone and iodine. Which information should the nurse identify that is least likely to cause iodine deficiency and hypothyroidism? 1. Eating large amounts of shellfish 2. Using prescribed lithium carbonate 3. Eating large amounts of turnips or rutabagas 4. Living in an area where iodine is deficient in the soil Answer: 1 Explanation: 1. Shellfish contains iodine. 2. Drugs such as lithium carbonate interfere with thyroid hormone synthesis. 3. Foods such as turnips and rutabagas interfere with thyroid hormone synthesis. 4. Living in an area where iodine is deficient in the soil may lead to thyroid deficiency and hypothyroidism. Page Ref: 575 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

16 ..

17) The nurse is reviewing orders for a patient in myxedema coma. Which prescription should the nurse question before administering to this patient? Select all that apply. 1. Regular insulin IV at 5 units per hour 2. Cooling blanket 3. Methimazole (Tapazole) 15 mg PO daily 4. Pulse oximetry and vital signs hourly 5. Serum TSH level daily Answer: 1, 2, 3 Explanation: 1. Myxedema coma is characterized by hypoglycemia. There is no evidence that IV insulin is indicated, and administering it would likely be harmful to an already hypoglycemic patient. 2. Patients with myxedema are often hypothermic, and a cooling blanket would be harmful. 3. Methimazole (Tapazole) interferes with thyroid hormone and would be contraindicated for a patient in myxedema coma. 4. Hourly vital signs with oximetry are appropriate for this patient. 5. Daily serum TSH monitoring is appropriate for this patient. Page Ref: 576 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

17 ..

18) The nurse is describing the manifestations of myxedema coma to a patient with hypothyroidism. What should the nurse identify as precipitating factors for this health problem? Select all that apply. 1. Stroke 2. Pneumonia 3. Excessive use of thyroid replacement medications 4. Excessive use of central nervous system stimulants 5. Exposure to excessive heat and humidity Answer: 1, 2 Explanation: 1. Myxedema coma may be precipitated by a stroke. 2. Myxedema coma may be precipitated by an infection such as pneumonia. 3. Excessive use of thyroid replacement medications would not precipitate myxedema coma. 4. Excessive use of central nervous system stimulants would not precipitate myxedema coma. 5. Exposure to heat and humidity would not precipitate myxedema coma. Page Ref: 575 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

18 ..

19) The nurse is reviewing the laboratory results for a group of patients. Which set of results should the nurse identify as being consistent with primary hypothyroidism? 1. Elevated TSH, depressed T3 and T4 2. Elevated TSH, elevated T3 and T4 3. Depressed TSH, elevated T3 and T4 4. Depressed TSH, depressed T3 and T4 Answer: 1 Explanation: 1. Primary hypothyroidism emanates from the thyroid gland itself. Laboratory analysis will indicate an elevated TSH, as the pituitary attempts to stimulate the thyroid gland to produce thyroid hormone, and the thyroid hormone levels T3 and T4 will be low. 2. Laboratory analysis will indicate an elevated TSH, as the pituitary attempts to stimulate the thyroid gland to produce thyroid hormone. Thyroid hormone levels T3 and T4 will not be elevated. 3. TSH is depressed in hyperthyroidism. 4. TSH is depressed in hyperthyroidism. Page Ref: 569 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

19 ..

20) The nurse is caring for a patient with untreated hypothyroidism. For which health problem should the nurse assess this patient? Select all that apply. 1. Elevated serum cholesterol 2. Anemia 3. Hyperglycemia 4. Hypernatremia 5. Decreased serum LDL Answer: 1, 2 Explanation: 1. Untreated hypothyroidism increases the risk for abnormalities in lipid metabolism. 2. Anemia is common in untreated hypothyroidism. 3. Hyperglycemia is not associated with untreated hypothyroidism. 4. Hypernatremia is not associated with untreated hypothyroidism. 5. Untreated hypothyroidism increases the risk for abnormal lipid metabolism. Page Ref: 573 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

20 ..

21) The nurse is teaching a patient who has a diagnosis of hypothyroidism about the importance of dietary fiber. Which statement by the patient indicates that teaching has been effective? Select all that apply. 1. "I will drink a full glass of water with my fiber pill each morning." 2. "I will snack on fruit rather than potato chips." 3. "I will take an over-the-counter fiber pill each morning with my levothyroxine." 4. "I will increase my intake of protein sources such as meat and eggs." 5. "I will read the nutrition labels and choose foods with high carbohydrate content." Answer: 1, 2 Explanation: 1. A full glass of water should be taken with fiber tablets to reduce the risk of intestinal blockage. 2. Fruit is a high-fiber food and an appropriate choice for a patient who needs a high-fiber diet. 3. The patient should not ingest a high-fiber source at the same time as thyroid replacement medications, as the fiber will interfere with absorption of the medication. 4. Meat and eggs are not good sources of fiber. 5. This patient should look for fiber content rather than carbohydrate content on labels. Page Ref: 576 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

21 ..

22) The nurse is screening a group of patients for risk factors related to thyroid cancer. Which patient should the nurse recognize as having the highest risk for developing thyroid cancer? 1. A 75-year-old patient with a history of sinus infections in childhood 2. A 70-year-old patient who refinishes furniture as a hobby 3. An 80-year-old patient whose diet consists largely of red meat 4. An 85-year-old patient who works outdoors without sunscreen Answer: 1 Explanation: 1. The most consistent risk factor for thyroid cancer is exposure to ionizing radiation to the head and neck during childhood. For example, many adults in their 60s, 70s, and 80s received x-ray treatments for colds, tonsillitis, acne, and sinus infections during childhood. 2. Exposure to products used in refinishing furniture is not a risk factor for thyroid cancer. 3. A diet of red meat is not a risk factor for thyroid cancer. 4. Failing to use sunscreen when working outdoors is not a risk factor for thyroid cancer. Page Ref: 579 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

22 ..

23) The nurse is reviewing the manifestations of hyperparathyroidism with a patient. Which statement by the patient indicates that teaching has been effective? Select all that apply. 1. "Hyperparathyroidism can cause the kidneys to keep calcium and excrete phosphorus." 2. "Calcium and phosphorus leave the bones and make them weak." 3. "Calcium is deposited in soft tissues." 4. "Kidney stones can develop." 5. "The kidneys work to raise blood pH and retain potassium." Answer: 1, 2, 3, 4 Explanation: 1. Hyperparathyroidism is characterized by increased resorption of calcium and excretion of phosphate by the kidneys, which increases the risk of hypercalcemia and hypophosphatemia. 2. Hyperparathyroidism increases the release of calcium and phosphorus by the bones, with resultant bone decalcification. 3. The increase in PTH affects the kidneys and bones, leading to the deposit of calcium in soft tissues. 4. Renal calculi can form. 5. Hyperparathyroidism causes the kidneys to lower blood pH and excrete potassium. Page Ref: 579 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

23 ..

24) The nurse is instructing a patient about the symptoms of hyperparathyroidism. Which symptom should the nurse include in this discussion? Select all that apply. 1. Abdominal pain 2. Dysrhythmias 3. Hypertension 4. Diarrhea 5. Reduced urine output Answer: 1, 2, 3 Explanation: 1. Hyperparathyroidism can cause abdominal pain. 2. Hyperparathyroidism can cause dysrhythmias. 3. Hyperparathyroidism can cause hypertension. 4. Diarrhea is not associated with hyperparathyroidism. 5. Reduced urine output is not associated with hyperparathyroidism. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with endocrine disorders.

24 ..

25) A patient with hyperparathyroidism is taking digoxin (Lanoxin). For what should the nurse assess this patient? 1. Toxic effects of digoxin (Lanoxin) 2. Evidence the medication dose needs to be increased 3. Onset of polyuria 4. Muscle weakness and atrophy Answer: 1 Explanation: 1. Hyperparathyroidism increases sensitivity to cardiotonic glycosides such as digoxin. The patient should be assessed for toxic effects of this medication. 2. The medication dose will unlikely need to be increased. 3. Polyuria is a manifestation of hyperparathyroidism. 4. Muscle weakness and atrophy are manifestations of hyperparathyroidism. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

25 ..

26) The nurse is developing a plan of care for a patient with hyperparathyroidism and a serum calcium level of 12.0 mg/dL. What should be included in the plan? Select all that apply. 1. Promoting ambulation and mobility 2. Discussing a change from ordered thiazide diuretics to another type of diuretic with healthcare provider 3. Teaching to increase daily oral intake of fluids 4. Encouraging supplementation of fat-soluble vitamins 5. Encouraging use of calcium-based antacids for indigestion Answer: 1, 2, 3 Explanation: 1. Treatment of hyperparathyroidism focuses on reducing elevated serum calcium levels. Patients with mild hypercalcemia are urged to keep active and avoid immobilization. 2. Patients with mild hypercalcemia are urged to avoid thiazide diuretics. 3. Patients with mild hypercalcemia are urged to increase fluid intake. 4. Patients with mild hypercalcemia are urged to avoid large doses of vitamins A and D. 5. Patients with mild hypercalcemia are urged to avoid antacids containing calcium. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Integrity Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

26 ..

27) A patient with hyperparathyroidism secondary to renal failure is prescribed calcimimetic. What should the nurse instruct the patient about this medication? 1. It increases the sensitivity of the calcium-sensing receptors of the parathyroid gland to serum calcium. 2. It blocks calcium receptors in the nervous and musculoskeletal systems. 3. It decreases resorption of calcium in the distal renal tubule. 4. It binds calcium to bile salts that are then excreted through the GI tract. Answer: 1 Explanation: 1. Calcimimetic increases the sensitivity of the calcium-sensing receptors of the parathyroid gland to serum calcium. The effect is decreased secretion of PTH and reduced serum calcium and phosphorus. 2. Calcimimetic does not block calcium receptors in the nervous and musculoskeletal systems. 3. Calcimimetic does not decrease the resorption of calcium in the distal renal tubule. 4. Calcimimetic does not bind calcium to bile salts to excrete through the GI tract. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

27 ..

28) The nurse notes that a patient who has hypoparathyroidism has a serum calcium level of 6.8 mg/dL. What would be a priority problem when planning care for this patient? 1. Potential for injury 2. Safety concerns because of confusion 3. Changes in renal function 4. Problems with oxygenation Answer: 1 Explanation: 1. The patient with hypocalcemia has a potential for injury because of the effects of the low calcium level on bone structure. Calcium is also needed for muscle and nerve function. 2. Confusion is not a manifestation of hypoparathyroidism and low calcium level. 3. Renal function changes are not a manifestation of hypoparathyroidism and low calcium level. 4. Problems with oxygenation are not a manifestation of hypoparathyroidism and low calcium level. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

28 ..

29) The nurse is caring for a patient with hypoparathyroidism. What action should the nurse expect to perform to help this patient with a low calcium level? Select all that apply. 1. Administering calcium tablets as prescribed 2. Arranging for a dietary consult regarding foods high in calcium 3. Restricting fluids 4. Administering intravenous IV calcium gluconate 5. Administering calcimimetic Answer: 1, 2, 4 Explanation: 1. Treatment of hypoparathyroidism focuses on increasing calcium levels. Longterm therapy includes supplemental calcium. 2. Treatment of hypoparathyroidism focuses on increasing calcium levels. Long-term therapy includes increased dietary calcium. 3. Fluids are not restricted in the treatment of hypoparathyroidism. 4. Treatment of hypoparathyroidism focuses on increasing calcium levels. Intravenous calcium gluconate is given immediately to reduce tetany. 5. Treatment of hypoparathyroidism focuses on increasing calcium levels. Calcimimetic would reduce the amount of calcium in the body. Page Ref: 580 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.2 Describe the pathophysiology and manifestations of disorders of the parathyroid glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

29 ..

30) The nurse suspects that a patient with chronic hyperfunction of the adrenal cortex has an infection. What did the nurse assess to come to this conclusion? 1. General feeling of malaise 2. Recent weight loss 3. Muscular tremors 4. Sense of nervous energy Answer: 1 Explanation: 1. Elevated cortisol levels impair the immune response and put the patient with Cushing syndrome at risk for infection. A generalized feeling of malaise may be the primary manifestation of infection. 2. A weight change is not a manifestation of infection in a patient with chronic hyperfunction of the adrenal cortex. 3. Muscle tremors are not a manifestation of infection in a patient with chronic hyperfunction of the adrenal cortex. Patients typically experience muscle weakness and fatigue rather than tremors. 4. Nervous energy is not a manifestation of infection in a patient with chronic hyperfunction of the adrenal cortex. Patients typically experience muscle weakness and fatigue rather than increased energy. Page Ref: 583 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

30 ..

31) The nurse is reviewing health history information for a group of patients. Which patient should the nurse identify as being at the lowest risk of developing Cushing syndrome? 1. The patient who received radioactive iodine treatment for hyperthyroidism 2. The patient receiving treatment for rheumatoid arthritis 3. The patient who has had an organ transplant 4. The patient receiving chemotherapy to treat a brain tumor Answer: 1 Explanation: 1. The patient who received radioactive iodine treatment for hyperthyroidism is not at increased risk for Cushing syndrome. 2. Patients receiving treatment for rheumatoid arthritis are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome. 3. Patients with organ transplants are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome. 4. Patients receiving chemotherapy are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome. Page Ref: 581 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

31 ..

32) A patient is prescribed prednisone (Dexasone) for a chronic health problem. Which sign of Cushing syndrome should the nurse instruct this patient to report to the healthcare provider? Select all that apply. 1. Fat deposits in the abdominal and clavicle regions 2. Muscle weakness and wasting in the extremities 3. Delayed wound healing 4. Development of varicose leg veins 5. Hypotension Answer: 1, 2, 3 Explanation: 1. Symptoms of Cushing syndrome include obesity and a redistribution of body fat to the abdominal region (central obesity), the upper back, and under the clavicle. 2. Changes in protein metabolism cause muscle weakness and wasting, especially in the extremities. 3. Poor wound healing is common. 4. Varicose veins are not a manifestation of Cushing syndrome. 5. Hypotension is not a manifestation of Cushing syndrome. Page Ref: 581 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

32 ..

33) The nurse is assessing a patient with Cushing syndrome. Which finding should the nurse report for immediate follow-up? 1. Serum potassium 2.5 mEq/L and blood pressure 150/90 mmHg 2. Serum sodium 145 mEq/L and reports of muscle weakness 3. Serum calcium 11 mg/dL and reports of feelings of depression 4. Serum phosphorus 3 mg/dL and hirsutism Answer: 1 Explanation: 1. Hypokalemia and hypertension occur with Cushing syndrome as potassium is lost and sodium is retained. 2. These findings do not need to be reported for immediate follow-up. 3. These findings do not need to be reported for immediate follow-up. 4. These findings do not need to be reported for immediate follow-up. Page Ref: 582 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

33 ..

34) A patient with suspected Cushing syndrome is prescribed a 24-hour urine collection. What should the nurse explain to the patient about the reason for this urine collection? 1. It measures the amount of cortisol in the urine over 24 hours. 2. At least 2000 mL of urine is required to perform the test. 3. It identifies urine specific gravity changes over a 24-hour period. 4. The 24-hour timeline reduces unwanted effects of medications excreted in the urine. Answer: 1 Explanation: 1. If the dexamethasone test is positive, a test for urinary free cortisol is made. This measures the amount of cortisol in the urine over 24 hours. 2. The 24-hour urine collection is not performed because 2 L of urine is needed. 3. The 24-hour urine collection does not measure urine specific gravity changes. 4. The 24-hour urine collection is not performed to ensure medication excretion in the urine. Page Ref: 582 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

34 ..

35) A patient with a non-ACTH-producing adrenal cortex tumor is scheduled for a surgical procedure to remove the tumor. Which statement by the patient indicates that teaching about the procedure has been effective? 1. "The adrenal gland with the tumor will be removed." 2. "I will need to take adrenal hormones for the rest of my life." 3. "The tumor will be removed by the transsphenoidal route." 4. "I will receive IV cortisol in preparation for the surgery." Answer: 1 Explanation: 1. When Cushing syndrome is caused by a non-ACTH-producing adrenal cortex tumor, an adrenalectomy may be performed to remove the tumor and the affected adrenal gland. 2. Only one adrenal gland is usually involved. As there is a remaining adrenal gland, patients do not need lifetime adrenal hormone replacement. 3. Adrenal glands are not removed via the transsphenoidal route. 4. The patient with Cushing syndrome is already experiencing elevated cortisol levels; IV cortisol is not indicated prior to adrenalectomy. Page Ref: 582 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

35 ..

36) The nurse is preparing to assess a patient with Cushing syndrome. Which finding should the nurse expect to assess in this patient? Select all that apply. 1. Weight gain 2. Auscultatory lung crackles 3. Jugular vein distention 4. Peripheral edema 5. Hypotension Answer: 1, 2, 3, 4 Explanation: 1. The excess cortisol secretion associated with Cushing syndrome results in sodium and water resorption, causing symptoms of fluid volume excess such as weight gain. 2. The nurse may note crackles and wheezes on lung auscultation. 3. The nurse may note jugular vein distention. 4. The excess cortisol secretion associated with Cushing syndrome results in sodium and water resorption, causing symptoms of fluid volume excess and edema. 5. Hypotension is not an expected assessment finding in the patient with Cushing syndrome. Page Ref: 583 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

36 ..

37) The nurse prepares teaching material for a patient with Cushing syndrome. Which statement about the risk for infection should the nurse alter before teaching? 1. "Epidermal hypertrophy restricts macrophage activity." 2. "Cortisol affects protein synthesis." 3. "Cortisol inhibits collagen synthesis." 4. "The resulting edema impairs blood flow to tissues." Answer: 1 Explanation: 1. Glucocorticoid excess inhibits fibroblasts, resulting in loss of collagen and connective tissue. Thinning of skin, poor wound healing, and frequent skin infections result. Macrophage activity is not a related action. 2. Increased cortisol affects protein synthesis, causing delayed wound healing and further inhibiting resistance to infection. 3. Increased cortisol inhibits collagen formation, which results in epidermal atrophy, further inhibiting resistance to infection. 4. Impaired blood flow to edematous tissue results in altered cellular nutrition, which increases the potential for infection. Page Ref: 581 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

37 ..

38) The nurse is planning a teaching session for a patient with a new diagnosis of adrenoleukodystrophy. What topic should the nurse include? 1. Why genetic counseling is included in the plan of care 2. The role of autoimmunity in the development of the disorder 3. The role of anticoagulants in the development of the disorder 4. The surgical site for transsphenoidal entry, using a diagram Answer: 1 Explanation: 1. Adrenoleukodystrophy is an X-linked disorder characterized by an accumulation of very long chain fatty acids in the adrenal cortex, testes, brain, and spinal cord. 2. Adrenoleukodystrophy is not an autoimmune disorder. 3. Adrenoleukodystrophy is not caused by anticoagulant therapy. 4. Adrenoleukodystrophy is not treated with surgery. Page Ref: 584 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

38 ..

39) A patient with Addison disease is experiencing weakness and abdominal pain and has an oral temperature of 102°F and blood pressure of 70/35 mmHg. Which patient information should the nurse identify as potentially causing these manifestations? Select all that apply. 1. "I had my tonsils out last week." 2. "I have a pressure ulcer from sleeping in my recliner." 3. "I have been using a tanning bed." 4. "I take my prednisone (Deltasone) every day." 5. "I have been increasing my intake of calcium-rich foods." Answer: 1, 2 Explanation: 1. Addisonian crisis is a life-threatening response to acute adrenal insufficiency. Surgery is one trigger. 2. Addisonian crisis is a life-threatening response to acute adrenal insufficiency. One trigger is acute systemic illness such as sepsis from a pressure ulcer. 3. The use of tanning beds is not associated with Addisonian crisis. 4. Patients are prescribed prednisone or related glucocorticoids to treat Addison disease; this is not a cause of Addisonian crisis. 5. Intake of calcium-rich foods is not associated with Addisonian crisis. Page Ref: 585 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

39 ..

40) A patient recovering from a closed head injury has a urine specific gravity of 1.010 g/mL. The previous intake and output totals were 1200 mL intake and 10,000 mL output. Which prescription from the healthcare provider should the nurse question for this patient? 1. Desmopressin (Minirin) 0.2 mg by mouth daily 2. Oral fluid restriction of 800 mL per day 3. 3% normal saline at 100 mL per hour 4. Computed tomography scan of head Answer: 1 Explanation: 1. Desmopressin is administered intranasally or parenterally and is the treatment of choice for SIADH that cannot be treated by correcting the underlying cause. 2. Strategies for correcting the underlying cause of SIADH include treating the hyponatremia and replacing fluid based on a calculation that adds fluid losses from the prior hour to an hourly base rate of fluid. 3. Strategies for correcting the underlying cause of SIADH include treating the hyponatremia with intravenous hypertonic saline. 4. A CT scan is an appropriate diagnostic tool. Page Ref: 590 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.4 Describe the pathophysiology and manifestations of disorders of the pituitary gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

40 ..

41) A patient with hyperthyroidism is experiencing vision changes. What teaching should the nurse provide to preserve this patient's sight? Select all that apply. 1. Apply eye shields. 2. Instill artificial tears. 3. Wear eyeglasses with tinted lenses. 4. Apply warm compresses to the eyes every 4 hours. 5. Notify the healthcare provider about vision changes. Answer: 1, 2, 3, 5 Explanation: 1. Measures to protect the eyes from injury and maintain visual acuity include applying eye shields. 2. Measures to protect the eyes from injury and maintain visual acuity include instilling artificial tears to moisten the eyes. 3. Measures to protect the eyes from injury and maintain visual acuity include using tinted glasses. 4. The application of warm compresses would not help preserve this patient's visual acuity. 5. Measures to protect the eyes from injury and maintain visual acuity include notifying the healthcare provider about vision changes. Page Ref: 571 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

41 ..

42) The nurse in the postanesthesia care area is concerned that a patient recovering from a subtotal thyroidectomy is experiencing postoperative complications. What finding led the nurse to come to this conclusion? Select all that apply. 1. Hoarse voice 2. Restlessness and irritability 3. Blood pressure 92/56 mmHg 4. Heart rate 116 beats per minute 5. High-pitched, squeaky sound with breathing Answer: 3, 4, 5 Explanation: 1. Hoarseness is expected immediately after a subtotal thyroidectomy. It is too soon to suspect laryngeal nerve damage in this patient. 2. Restlessness and irritability are vague symptoms that could result from the anesthesia, the surgical procedure, or recovery. This is not considered a postoperative complication. 3. A postoperative complication is hemorrhage, which can manifest as a dropping blood pressure. 4. A postoperative complication is hemorrhage, which can manifest as a rapid heart rate. 5. Stridor, a high-pitched, squeaky sound, is heard in acute airway obstructions. Page Ref: 570 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with endocrine disorders.

42 ..

43) A patient with Addison disease is experiencing problems with fluid balance. What actions should the nurse take to help this patient? Select all that apply. 1. Teach to sit and stand slowly. 2. Monitor cardiac monitor rhythm. 3. Turn and reposition every 2 hours while awake. 4. Weigh the patient daily at the same time and in the same clothing. 5. Encourage oral fluid intake of 3000 mL/day and increased salt intake. Answer: 1, 2, 4, 5 Explanation: 1. The nurse should teach the patient to sit and stand slowly, and provide assistance as necessary. Extracellular fluid volume deficit causes orthostatic hypotension, dizziness, and possible loss of consciousness. These manifestations increase the risk of injury from falls. 2. A drop in aldosterone levels can reduce renal excretion of potassium, leading to increased blood levels and the potential for cardiac dysrhythmias. 3. Turning and repositioning would be beneficial to maintain skin integrity, not to address a fluid imbalance. 4. The nurse should weigh the patient daily at the same time and in the same clothing because dehydration is manifested by weight loss. 5. The nurse should encourage an oral fluid intake of 3000 mL/day and an increased salt intake. Cortisol deficiency increases fluid loss, leading to extracellular fluid volume depletion. Oral fluid replacement is necessary to balance this loss. An increase in dietary sodium can reduce the hyponatremia characteristic of adrenal insufficiency. Page Ref: 586-587 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 19.3 Describe the pathophysiology and manifestations of disorders of the adrenal glands, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

43 ..

44) A patient with hypothyroidism is prescribed levothyroxine sodium (Synthroid). What dietary adjustment should the nurse instruct the patient to make? Select all that apply. 1. Avoid eating walnuts. 2. Avoid all grapefruit or citrus fruits. 3. Restrict the intake of foods high in fiber. 4. Reduce the intake of green leafy vegetables. 5. Take the medication 30 minutes before eating breakfast in the morning. Answer: 1, 3, 5 Explanation: 1. The patient should be instructed to avoid excessive intake of foods that are known to inhibit thyroid hormone utilization, such as walnuts. 2. There is no reason for the patient to avoid grapefruit or other citrus fruits. 3. The patient should be instructed to avoid excessive intake of foods that are known to inhibit thyroid hormone utilization, such as high-fiber foods. 4. There is no reason for the patient to limit the intake of green leafy vegetables. 5. The patient should be instructed to take the thyroid preparation in the morning 30 minutes before eating to reduce the possibility of insomnia. Page Ref: 576 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 19.1 Describe the pathophysiology and manifestations of disorders of the thyroid gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with endocrine disorders.

44 ..

45) A patient recovering from a head injury is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which should the nurse expect to be prescribed for this patient? Select all that apply. 1. Restrict fluids. 2. Increase oral fluids. 3. Provide a loop diuretic. 4. Administer Conivaptan. 5. Administer demeclocycline. Answer: 1, 3, 4, 5 Explanation: 1. Fluid intake is restricted to gradually reduce total body water. 2. Increasing fluids will exacerbate hyponatremia in SIADH. 3. Loop diuretics such as furosemide are used to decrease fluid volume. 4. Vasopressin receptor antagonist, such as Conivaptan, is used to correct hyponatremia. 5. Demeclocycline is a tetracycline antibiotic that suppresses ADH activity, resulting in increased urine production. Page Ref: 590 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 19.4 Describe the pathophysiology and manifestations of disorders of the pituitary gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with endocrine disorders.

45 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 20 Nursing Care of Patients with Diabetes Mellitus 1) A patient at risk for the development of type 2 diabetes mellitus asks why weight loss will reduce risk of developing the health problem. Which response by the nurse is most accurate? 1. "The amount of foods taken in require more insulin to adequately metabolize them, resulting in diabetes." 2. "Excess body weight impairs the body's release of insulin." 3. "Thin people are less likely to become diabetic." 4. "The physical inactivity associated with obesity causes a reduced ability by the body to produce insulin." Answer: 2 Explanation: 1. This is not a true statement. 2. Beta cells of the body release insulin. Their actions are hindered as the amount of adipose tissue in the body increases. 3. While obesity is a risk factor for the development of diabetes, this does not answer the patient's question. 4. Inactivity is directly linked to obesity, but it does not present a direct tie to the production of insulin. Page Ref: 597 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

1 ..

2) A patient recently diagnosed with type 1 diabetes mellitus does not understand why the disease developed because the patient is thin and eats all of the time. What is the most appropriate response by the nurse? 1. "Thin people can be diabetic, too." 2. "Your condition makes it impossible for you to gain weight." 3. "Diabetes makes it difficult for your body to obtain energy from the foods you eat." 4. "Your lab tests indicate the presence of diabetes." Answer: 3 Explanation: 1. While the statement about diabetics being thin is correct, it does not answer the patient's question. 2. It is not impossible for diabetics to gain weight. 3. The patient with type 1 diabetes mellitus is unable to obtain the needed glucose for the body's cells, due to the lack of insulin. Patients diagnosed with type 1 diabetes mellitus experience polyphagia and are often thin. 4. Although the laboratory tests might indicate the presence of diabetes, it does not meet the patient's needs for teaching. Page Ref: 598 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

2 ..

3) An older patient without polyuria, polydipsia, or polyphagia has a serum glucose level of 130 mg/dL. What should the nurse conclude about this patient? 1. The patient might have eaten a meal with high sugar content prior to the testing.

2. The laboratory results might be erroneous. 3. The patient has type 1 diabetes mellitus. 4. The patient will need to be assessed for other manifestations of diabetes. Answer: 4 Explanation: 1. A slight elevation in serum glucose level warrants further investigation. 2. There is no reason to question the laboratory results at this time. 3. There is inadequate information to make a diagnosis of type 1 diabetes mellitus. 4. Older adults with diabetes might not present with the classic symptoms of polyuria, polyphagia, or polydipsia. Symptoms of diabetes in older patients can include hypotension, periodontal disease, infections, and strokes. A slight elevation in serum glucose level warrants further investigation. Page Ref: 599 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

3 ..

4) The nurse notes that a patient who has not been diagnosed with diabetes has a hemoglobin A1C level of 6%. What should the nurse suspect is occurring with the patient? 1. Severe hyperglycemia 2. Consistent with diabetes 3. Normal results 4. High risk for developing diabetes Answer: 4 Explanation: 1. This is not severe hyperglycemia. If it were, the nurse would immediately notify the healthcare provider. 2. Diabetes is fasting blood glucose level of 126 mg/dL or greater. 3. A normal fasting blood glucose level is less than or equal to 100 mg/dL. 4. A hemoglobin A1C level of 5.7% to 6.4% indicates a high risk for developing diabetes. Page Ref: 609 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with diabetes mellitus.

4 ..

5) A patient recently diagnosed with diabetes wants to check the urine for glucose instead of using capillary blood because of the cost. Which response should the nurse make to the patient? 1. "Urine testing is best when combined with serum testing." 2. "Urine testing is as reliable as finger stick testing." 3. "Yes, urine testing is cheaper than glucose test strips." 4. "Would you like to switch to this method of monitoring?" Answer: 1 Explanation: 1. Urine testing may be used for glucose, ketones, and albumin. Urine analysis for increased glucose and ketones indicates hyperglycemia and ketosis. Urine tests for albumin are used to detect the early onset of kidney damage. 2. Advising the patient the method of testing is not reliable is not entirely correct and does not provide needed information to the patient. 3. Urine testing is not necessarily less expensive than glucose test strips. 4. It is inappropriate for the nurse to make such a suggestion about the method of testing to be utilized by the patient. Page Ref: 609 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 2. Consider intraprofessional care for patients with diabetes mellitus.

5 ..

6) A patient with type 1 diabetes mellitus who had one episode of vomiting in the past 2 hours asks if the routine insulin injection should be taken. What action by the nurse is best at this time? 1. Contact the physician. 2. Explain the need to take the insulin. 3. Document the refusal and continue on with the planned care. 4. Check the patient's fasting serum glucose level. Answer: 2 Explanation: 1. Contacting the physician at this time is premature. 2. Taking the insulin is the best course of action. The usual dose of insulin should be taken even if ill. 3. Documentation of the patient's refusal is premature, as efforts have not been made to discuss the need for the medication. 4. Checking the morning fasting serum glucose will not reflect the patient's current glucose level. Page Ref: 626 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.5 Design best practices of self-care management of DM related to diet planning, sick-day management, and exercise. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

6 ..

7) A patient beginning insulin for type 2 diabetes is experiencing blurred vision and is concerned about becoming blind. What response by the nurse is most appropriate? 1. "I will make an appointment for you to see an ophthalmologist." 2. "I will call the physician to report your symptoms." 3. "Blurry vision is very common. Do not worry." 4. "This is a normal response when insulin therapy is initiated." Answer: 4 Explanation: 1. It is beyond the scope of practice for the nurse to make a referral to another physician. 2. Contacting the physician is premature. 3. Telling the patient it is "nothing" minimizes the concerns voiced, and does not provide adequate information to the patient. 4. Vision changes are normal during the first weeks of insulin therapy. They will gradually resolve. Page Ref: 613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

7 ..

8) A patient with diabetes is diaphoretic, has a heart rate of 112 beats per minute, and is feeling nervous and shaky. What action should the nurse take first? 1. Provide the patient with a snack of milk and crackers. 2. Administer insulin utilizing the prescribed sliding scale dosages. 3. Contact the laboratory and order a serum glucose level. 4. Obtain a capillary serum glucose level reading with a glucose meter. Answer: 4 Explanation: 1. While the patient is demonstrating manifestations consistent with hypoglycemia, providing a snack is not the first action the nurse should take. 2. The patient is hypoglycemic, so insulin administration would be incorrect, as it would only add to the problem. 3. It would be more appropriate to use the nursing unit's glucometer than to wait for the laboratory to obtain a reading. In addition, there is no indication an order for laboratory values exists. 4. The first action would be to verify the patient's blood glucose level. Page Ref: 603-604 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with diabetes mellitus.

8 ..

9) The nurse is preparing to administer insulin to an underweight patient. Which action should the nurse take when providing this injection? Select all that apply. 1. Ensure insulin is at room temperature. 2. Make sure no air bubbles are present in the syringe. 3. Massage the site of insertion. 4. Rotate injection sites. 5. Insert the needle at a 90-degree angle. Answer: 1, 2, 4 Explanation: 1. Insulin is used at room temperature. 2. No air bubbles should be in the syringe. This will reduce complications and will aid in ensuring correct dosages. 3. Massage of administration sites will alter absorption rates. 4. Insulin injection sites should be rotated. 5. The thin individual will require an administration angle of 45 degrees. Page Ref: 614-616 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus. 10) While conducting an educational session for a group of patients regarding the incidence and prevalence of diabetes, the nurse explains that approximately 25.1 million people have been diagnosed with the disorder, but 7.2 million people have not. Statistically, what is the percentage of people who have undiagnosed diabetes? Calculate to the first decimal point. Answer: 28.6% Explanation: To calculate this percentage the nurse should divide the number who are not diagnosed by the total number of people with the disorder or 7.2/25.1 = 0.286. Then multiply this value by 100 or 0.286 × 100 = 28.6%. Page Ref: 595 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning 9 ..

Learning Outcome: 20.1 Describe the prevalence and incidence of diabetes mellitus (DM). MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus. 11) The nurse is conducting an educational session with a patient who is newly diagnosed with diabetes. Which statement indicates that additional teaching is required? 1. "6 million people have diabetes." 2. "23.1 million people have been diagnosed with diabetes." 3. "84.1 million people have prediabetes." 4. "7.2 million people have diabetes but have not been diagnosed." Answer: 1 Explanation: 1. Approximately 30.3 million people have diabetes. 2. This chronic illness affects an estimated 23.1 million people. 3. Approximately 84.1 million people have prediabetes. 4. An estimated 7.2 million are undiagnosed. Page Ref: 595 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 20.1 Describe the prevalence and incidence of diabetes mellitus (DM). MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

10 ..

12) The nurse is teaching a patient with diabetes about the illness. Which patient statement about pancreatic cells indicates that teaching has been effective? Select all that apply. 1. Alpha cells produce glucagon. 2. Beta cells secrete insulin. 3. Cephalon cells produce creatine. 4. Delta cells produce somatostatin. 5. Epsilon cells produce erythropoietin. Answer: 1, 2, 4 Explanation: 1. Alpha cells produce the hormone glucagon, which stimulates the breakdown of glycogen in the liver, the formation of carbohydrates in the liver, and the breakdown of lipids in both the liver and adipose tissue. 2. Beta cells secrete the hormone insulin, which facilitates the movement of glucose across cell membranes into cells, decreasing blood glucose levels. 3. Cephalon cells are not pancreatic cells. 4. Delta cells produce somatostatin, which acts within the islets of Langerhans to inhibit the production of both glucagon and insulin. It also slows gastrointestinal motility, allowing more time for food to be absorbed. 5. Epsilon cells are not pancreatic cells. Page Ref: 596 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 20.1 Describe the prevalence and incidence of diabetes mellitus (DM). MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

11 ..

13) The nurse is instructing a 5-year-old patient with diabetes mellitus. In which way should the nurse explain the action of insulin? 1. Building blocks that help make protein into strong muscles 2. A wagon that carries sugar into the cells of the body 3. A mud pie that makes the blood vessels thick and sticky 4. Salty potato chips that make people feel very thirsty Answer: 2 Explanation: 1. Insulin does not make protein into muscle. 2. The manifestations of type 1 DM are the result of a lack of insulin to transport glucose across the cell membrane into the cells. Insulin acts as a transport mechanism, allowing insulin into the body's cells. The analogy of the wagon carrying sugar into the cells of the body is appropriate for teaching a 5-year-old child about insulin therapy. 3. Insulin does not make blood vessels thick and sticky. 4. A scarcity of insulin may lead to polydipsia. Page Ref: 598 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

12 ..

14) The nurse is caring for a healthy patient who has a serum glucose level of 60 mg/dL. Which counterregulatory serum hormonal changes should the nurse expect to occur in this patient? Select all that apply. 1. Increased epinephrine levels 2. Increased growth hormone levels 3. Increased insulin levels 4. Decreased thyroxine levels 5. Decreased glucocorticoid levels Answer: 1, 2 Explanation: 1. If blood glucose falls, glucagon is released to raise hepatic glucose output, raising glucose levels. Epinephrine (often referred to as a glucose counterregulatory hormone) stimulates an increase in glucose in times of hypoglycemia, stress, growth, or increased metabolic demand. 2. If blood glucose falls, glucagon is released to raise hepatic glucose output, raising glucose levels. Growth hormone (often referred to as a glucose counterregulatory hormone) stimulates an increase in glucose in times of hypoglycemia, stress, growth, or increased metabolic demand. 3. Insulin is not released as a counterregulatory hormone. 4. Thyroxine level would increase with hypoglycemia. 5. Glucocorticoid levels would increase with hypoglycemia. Page Ref: 597 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.1 Describe the prevalence and incidence of diabetes mellitus (DM). MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

13 ..

15) A patient with type 1 diabetes mellitus voided 4000 mL of urine in the past 24 hours. The patient's skin turgor is poor, and the patient is reporting polyphagia and polydipsia. Which blood glucose level should the nurse expect when assessing this patient? 1. 60 mg/dL 2. 110 mg/dL 3. 125 mg/dL 4. 180 mg/dL Answer: 4 Explanation: 1. A blood glucose level of 60 mg/dL is hypoglycemia. Polyuria is not a manifestation of hypoglycemia. 2. A blood glucose level of 110 mg/dL is considered as being a normal blood glucose level. Polyuria is not a manifestation of a normal blood glucose level. 3. A blood glucose level of 125 mg/dL is considered an impaired blood glucose level. Polyuria is not a manifestation with this level. 4. Hyperglycemia causes serum hyperosmolality, drawing water from the intracellular spaces into the general circulation. The increased blood volume increases renal blood flow, and the hyperglycemia acts as an osmotic diuretic. The resulting osmotic diuresis increases urine output. This condition is called polyuria. When the blood glucose level exceeds the renal threshold for glucose usually about 180 mg/dL glucose is excreted in the urine, a condition called glucosuria. The decrease in intracellular volume and the increased urinary output cause dehydration. The mouth becomes dry and thirst sensors are activated, causing the person to drink increased amounts of fluid (polydipsia). Page Ref: 609 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with diabetes mellitus.

14 ..

16) The nurse is concerned that a patient with type 1 diabetes mellitus is at risk for developing diabetic ketoacidosis. What did the nurse assess to come to this conclusion? 1. Reports of anxiety 2. Pale, cool skin 3. Serum glucose level of 325 mg/dL 4. Ulcer on plantar aspect of right foot Answer: 3 Explanation: 1. Anxiety is a symptom of hypoglycemia. 2. Pale, cool skin is a symptom of hypoglycemia. 3. In diabetic ketoacidosis, the blood glucose level is above 250 mg/dL. 4. An ulcer is not a symptom of diabetic ketoacidosis. Page Ref: 601 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with diabetes mellitus.

15 ..

17) The nurse is assessing a patient who has a family history of type 2 diabetes mellitus. Which finding would require follow-up by the nurse? 1. A new prescription for levothyroxine (Synthroid) for hypothyroidism 2. Decreased waist-to-hip ratio through dietary changes 3. Delivery of a baby that weighed 8 lbs. and 12 ounces 4. A fasting blood glucose level of 89 mg/dL Answer: 1 Explanation: 1. Many drugs, including thyroid hormone, impair insulin secretion, precipitating DM in people with predisposing insulin resistance. 2. This is a desired finding. 3. This is an acceptable birth weight for a patient with diabetes. 4. This is a desirable level for a patient with diabetes. Page Ref: 297 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

16 ..

18) The nurse is reviewing data collected from a patient with a predisposition to developing insulin resistance. Which medication should the nurse identify as potentially causing this patient to develop diabetes? Select all that apply. 1. Nicotinic acid (Niacor) 2. Acetaminophen (Tylenol) 3. Levothyroxine (Synthroid) 4. Furosemide (Lasix) 5. Phenytoin (Dilantin) Answer: 1, 3, 4, 5 Explanation: 1. Many drugs impair insulin secretion, precipitating DM in people with predisposing insulin resistance. Examples include nicotinic acid (Niacor). 2. Acetaminophen (Tylenol) is not a medication that impairs insulin secretion, precipitating DM in people with predisposing insulin resistance. 3. Many drugs impair insulin secretion, precipitating DM in people with predisposing insulin resistance. Examples include levothyroxine (Synthroid), which is a thyroid hormone. 4. Many drugs impair insulin secretion, precipitating DM in people with predisposing insulin resistance. Examples include furosemide (Lasix), which is a thiazide diuretic. 5. Many drugs impair insulin secretion, precipitating DM in people with predisposing insulin resistance. Examples include phenytoin (Dilantin). Page Ref: 597 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

17 ..

19) The nurse is reviewing data collected for a patient's health history. Which factor should the nurse identify as increasing the patient's risk of developing type 2 diabetes mellitus? 1. Body mass index of 23 kg/m2 2. Blood pressure of 120/70 mmHg 3. Physical inactivity 4. Low waist-to-hip ratio Answer: 3 Explanation: 1. Patients with obesity, defined as being at least 20% over desired body weight or having a body mass index (BMI) of at least 27 kg/m2 are at major risk for type 2 DM. A patient with a body mass index of 23 kg/m2 is not the patient most at risk for type 2 DM. 2. A blood pressure of 120/70 mmHg is normal and carries no increased risk for type 2 DM. 3. Physical inactivity is a major risk factor for type 2 DM. 4. A high waist-to-hip ratio is a risk factor for type 2 DM. A low waist-to-hip ratio carries no increased risk of the disease. Page Ref: 599 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

18 ..

20) The nurse is trying to determine if a patient is experiencing manifestations of type 1 or type 2 diabetes mellitus. Which question should the nurse ask the patient to help determine the type? 1. "Have you been urinating in greater amounts than in the past?" 2. "Have you been drinking more liquids than in the past?" 3. "Have you been losing weight despite eating regularly?" 4. "Have you noticed any changes in your vision?" Answer: 3 Explanation: 1. Type 1 and type 2 diabetes have similar manifestations, especially polyuria and polydipsia. 2. Type 1 and type 2 diabetes have similar manifestations, especially polyuria and polydipsia. 3. Weight loss despite eating regularly is a manifestation of type 1 diabetes mellitus. The person with type 2 diabetes mellitus may lose weight but will be obese. 4. Vision changes are seen in both type 1 and type 2 diabetes mellitus. Page Ref: 599 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

19 ..

21) The nurse teaches about the prevalence of type 2 diabetes in older adults. Which should the nurse include about the number of older adults with diabetes? 1. 10 out of 100 will have type 2 diabetes.

2. 17 out of 100 will have type 2 diabetes. 3. 21 out of 100 will have type 2 diabetes. 4. 33 out of 100 will have type 2 diabetes Answer: 3 Explanation: 1. More than 10% will have type 2 diabetes. 2. More than 17% will have type 2 diabetes. 3. The Centers for Disease Control and Prevention estimates that 20.8% of the U.S. population over the age of 65 has DM. 4. Fewer than 33% will have type 2 diabetes. Page Ref: 599 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.2 Distinguish the pathophysiology, risk factors, manifestations, and complications of type 1 and type 2 DM. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

20 ..

22) The nurse is planning care for a patient with type 1 diabetes mellitus. Which action should the nurse identify as being the most effective to reduce the development of complications? 1. Self-monitoring of blood glucose levels 2. Performance of effective foot care 3. The necessity of a yearly eye examination 4. Knowing symptoms of urinary tract infections Answer: 1 Explanation: 1. The results of a 10-year DM Control and Complications Trial (DCCT), sponsored by the National Institutes of Health (NIH), have significant implications for the management of type 1 DM. People in the study who kept their blood glucose levels close to normal by frequent monitoring, several daily insulin injections, and lifestyle changes that included exercise and a healthier diet reduced by 60% their risk for the development and progression of complications involving the eyes, the kidneys, and the nervous system. 2. Effective foot care will not reduce the development of complications. 3. Yearly eye examinations will not reduce the development of complications. 4. Knowing the symptoms of a urinary tract infection will not reduce the development of complications. Page Ref: 609 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

21 ..

23) A patient with type 2 diabetes mellitus is scheduled for laparoscopic adjustable gastric banding (LAGB) surgery. What should the nurse explain to the patient about this procedure and diabetes? 1. "Evidence indicates positive outcomes for many patients with diabetes who undergo surgical weight loss procedures." 2. "Surgical procedures can be dangerous for patients with diabetes." 3. "Do you feel that a surgical weight loss procedure will cure your obesity?" 4. "This procedure is more appropriate for a patient who has a diagnosis of type 1 diabetes mellitus." Answer: 1 Explanation: 1. Studies of patients with DM who have gastrointestinal surgery for morbid obesity show improved insulin sensitivity and in some cases resolution of T2D. 2. While this is true, studies of patients with DM who have gastrointestinal surgery for morbid obesity show improved insulin sensitivity and in some cases resolution of T2D 3. The procedure is performed to decrease body weight. 4. The procedure is shown to elicit complete remission of type 2 DM in over three-fourths of the cases. Page Ref: 621 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 2. Consider intraprofessional care for patients with diabetes mellitus.

22 ..

24) The nurse instructs a patient with type 2 diabetes mellitus on the use of a glucometer for self-monitoring. Which patient return demonstration and statement about glucometer performance indicate that teaching has been effective? Select all that apply. 1. Correctly apply the blood to the meter strip. 2. Follow manufacturer's recommendation regarding cleaning of meter. 3. A patient with sickle cell anemia may need another way to check blood glucose levels. 4. Grapefruit juice should not be ingested when using the glucometer. 5. A sufficient amount of blood must be applied to the strip. Answer: 1, 2, 3, 5 Explanation: 1. Many factors may affect glucose meter performance, including correctly applying the blood to the meter strip. 2. Many factors may affect glucose meter performance, including failure to follow the manufacturer's recommendations regarding meter cleaning. 3. Many factors may affect glucose meter performance, including a diagnosis of anemia or sickle cell anemia. 4. The ingestion of grapefruit juice is not a known cause of poor meter performance. 5. Many factors may affect glucose meter performance, including insufficient amounts of blood on the meter strip. Page Ref: 610-611 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

23 ..

25) A patient with type 1 diabetes mellitus has a serum hematocrit level of 24%. What additional finding should the nurse report to the healthcare provider? 1. Capillary blood glucose of 60 mg/dL 2. Glycosylated hemoglobin of 7.0 3. The presence of albumin in urine 4. The presence of glucose in urine Answer: 1 Explanation: 1. Patients with low hematocrit levels will test falsely high. This patient's hematocrit is critically low. The serum glucose of 60 mg/dL may be a falsely high reading and the primary healthcare provider must be notified of this finding. 2. This glycosylated level does not require immediate notification of the healthcare provider. 3. The presence of albumin in the urine does not require immediate notification of the healthcare provider. 4. The presence of glucose in the urine does not require immediate notification of the healthcare provider. Page Ref: 610 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with diabetes mellitus.

24 ..

26) The nurse is teaching a patient with diabetes about self-management. What should the nurse include regarding medications to treat diabetes mellitus? 1. Patients with type 1 diabetes may achieve normal blood glucose levels with oral medications. 2. Patients with type 1 diabetes may progress to type 2 if blood glucose levels are not well controlled. 3. Patients with type 2 diabetes will always need an exogenous source of insulin. 4. Patients with type 2 diabetes may achieve normal blood glucose levels with a combination of oral medications and insulin. Answer: 4 Explanation: 1. Type 1 diabetes mellitus is not treated with oral medications. 2. Patients with diabetes do not progress from type 1 to type 2. 3. People with type 1 must have insulin. 4. People with type 2 diabetes mellitus are usually able to control glucose levels with an oral hypoglycemic medication, but they may require insulin if control is inadequate. Page Ref: 611 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

25 ..

27) The nurse is identifying patients at risk for needing insulin. Which patient should the nurse identify as potentially needing insulin to maintain a normal blood glucose level? Select all that apply. 1. Patients who are fasting or malnourished 2. Patients with type 2 diabetes who are diagnosed with an infection 3. Patients with type 2 diabetes who are undergoing surgical procedures 4. Patients with gestational diabetes 5. Patients receiving total parenteral nutrition Answer: 2, 3, 4 Explanation: 1. Fasting and malnourished patients are not at increased risk for insulin and are often hypoglycemic. 2. Insulin may be necessary for patients with diabetes mellitus who are experiencing an infection. 3. Insulin may be necessary for patients with diabetes mellitus who are scheduled for surgery. 4. Insulin may be necessary for patients with gestational diabetes mellitus. 5. Patients receiving total parenteral nutrition are not identified as potentially needing insulin. Page Ref: 611 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with diabetes mellitus.

26 ..

28) The nurse is caring for a patient with type 1 diabetes mellitus. Which patient statement requires immediate intervention by the nurse? 1. "I am allergic to eggs." 2. "I will take my lispro insulin 15 minutes before I eat breakfast." 3. "I won't mix my cloudy regular insulin with other insulins." 4. "I will not use insulin detemir in my insulin pump." Answer: 3 Explanation: 1. Allergies to eggs do not require immediate nursing intervention. 2. Lispro insulin is properly administered 15 minutes prior to a meal. 3. Regular insulin is clear in appearance. The patient may not understand insulin therapy or that regular insulin may be contaminated. 4. Insulin detemir is not used in insulin pumps. Page Ref: 611 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

27 ..

29) The nurse is reviewing a teaching tool created for insulin therapy. Which statement on the tool should be corrected? Select all that apply. 1. Lispro is a rapid-acting insulin. 2. Regular insulin can be administered intravenously. 3. NPH insulin may be mixed with lispro insulin. 4. Insulin detemir is administered prior to each meal. 5. Insulin glargine may be used to treat gestational diabetes. Answer: 4, 5 Explanation: 1. Lispro is a rapid-acting insulin. 2. Regular insulin can be administered intravenously. 3. NPH insulin may be mixed with lispro or regular insulin. 4. Insulin detemir is administered once or twice daily, not before each meal. 5. Insulin glargine is not used during pregnancy. Page Ref: 611-612 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

28 ..

30) A patient is prescribed 120 units of U-100 regular insulin to be administered at 0700 and 1600 hours. The prescription is written for an equivalent dose of U-500 insulin to be provided. How many units of U-500 insulin should be given? Record your answer rounding to the nearest whole number. Answer: 24 Explanation: U-500 units is 5 times more concentrated than U-100 insulin. The patient who is using 120 units of U-100 insulin will need 1/5 of the U-100 amount or 20% of the U-100 dose. 120 divided by 5 is 24. 24 units of U-500 insulin is equivalent to 120 units of U-100 insulin. Page Ref: 612 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

29 ..

31) A patient with diabetes mellitus has albuminuria, hypertension, and edema. What should the nurse expect to be prescribed for this patient? 1. Restrict activity. 2. Increase salt intake. 3. Review weight loss strategies. 4. Provide antibiotic therapy as prescribed. Answer: 3 Explanation: 1. Management of diabetic nephropathy includes control of hypertension with exercise. 2. Management of diabetic nephropathy includes control of hypertension with reduced salt intake. 3. Management of diabetic nephropathy includes control of hypertension with weight loss. 4. Management of diabetic nephropathy includes control of hypertension with ACE inhibitors. Page Ref: 606 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 2. Consider intraprofessional care for patients with diabetes mellitus.

30 ..

32) A patient with type 1 diabetes mellitus has difficulty swallowing and takes milk of magnesium every day for nausea and constipation. What should the nurse suspect is occurring with this patient? 1. Age-related changes 2. Visceral neuropathy 3. Peripheral neuropathy 4. Reaction to insulin injections Answer: 2 Explanation: 1. Difficulty swallowing and nausea are not specifically attributed to aging. 2. The visceral neuropathies cause various manifestations, depending on the area of the autonomic nervous system involved. Gastrointestinal dysfunction caused by autonomic neuropathy causes changes in upper gastrointestinal motility, leading to dysphagia and nausea. Constipation is one of the most common gastrointestinal manifestations associated with diabetes, possibly a result of hypomotility of the bowel. 3. Peripheral neuropathies affect the sensory and motor function of the extremities. 4. Swallowing, nausea, and constipation are not adverse effects of insulin. Page Ref: 607 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

31 ..

33) An older patient with type 2 diabetes mellitus is upset because family members do not believe the patient has an illness and resist helping with diet and activity modifications. What should the nurse suggest to help this patient? 1. Limit discussions about the illness with family members. 2. Store health-related items away from common family areas in the home. 3. Invite family to participate in a support group. 4. Explain the risk for family also to develop the illness. Answer: 3 Explanation: 1. Chronic illness affects all dimensions of an individual's life, as well as the lives of family members and significant others. Limiting discussions about the illness will not help them understand the impact diabetes has on the patient. 2. Storing health-related items away from common family areas in the home strengthens denial of the health problem. 3. Chronic illness affects all dimensions of an individual's life, as well as the lives of family members and significant others. Sharing with others who have similar problems provides opportunities for mutual support and problem solving. Using available resources improves the ability to cope. 4. There is no evidence to suggest that family members are at risk for developing diabetes. Page Ref: 625 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.5 Design best practices of self-care management of DM related to diet planning, sick-day management, and exercise. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

32 ..

34) The nurse is assessing a patient with type 2 diabetes mellitus. What question should the nurse ask to determine the patient's risk for a lower extremity amputation? Select all that apply. 1. "Do you use insulin or oral hypoglycemic agents?" 2. "What were your glycosylated hemoglobin values over the past year?" 3. "Do you have any problems with your eyes related to diabetes?" 4. "Do you have any problems with your kidney related to diabetes?" 5. "When were you first diagnosed with diabetes mellitus?" Answer: 2, 3, 4 Explanation: 1. The treatment of the diabetes is not a risk factor. 2. People with diabetes mellitus, especially those who are not meeting recommended glycemic goals, are at high risk for amputation of a lower extremity. 3. The high incidence of foot problems and amputations in people with diabetes mellitus is the result of angiopathy. 4. The high incidence of foot problems and amputations in people with diabetes mellitus is the result of angiopathy. 5. Age of diagnosis has no influence on the patient's risk of needing an amputation in the future. Page Ref: 608 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with diabetes mellitus.

33 ..

35) A group of patients with type 1 or 2 diabetes mellitus are planning to participate in an athletic triathlon. On which potential complication from this event should the nurse focus when teaching these patients? 1. Diabetic ketoacidosis 2. Hypoglycemia 3. Hyperosmolar hyperglycemic state 4. Impaired glucose tolerance Answer: 2 Explanation: 1. Diabetic ketoacidosis is not associated with exercise. 2. One reason for the development of severe hypoglycemia is too much exercise. 3. Hyperosmolar hyperglycemic state is not associated with exercise. 4. Exercise does not impact glucose tolerance. Page Ref: 603 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

34 ..

36) The nurse is teaching a patient with type 2 diabetes mellitus about glyburide (DiaBeta). Which medication should the nurse instruct the patient to monitor for dizziness, lightheadedness, and sweating if taken with the hypoglycemic agent? Select all that apply. 1. Ibuprofen 2. Ranitidine 3. Cetirizine 4. Metoprolol 5. Docusate sodium Answer: 1, 2, 4 Explanation: 1. Dizziness, lightheadedness, and sweating are symptoms of hypoglycemia. Monitor for hypoglycemia if the patient is also taking nonsteroidal anti-inflammatory agents (NSAIDs) such as ibuprofen. 2. Dizziness, lightheadedness, and sweating are symptoms of hypoglycemia. Monitor for hypoglycemia if the patient is taking ranitidine. 3. Zyrtec does not interact with glyburide. 4. Dizziness, lightheadedness, and sweating are symptoms of hypoglycemia. Monitor for hypoglycemia if the patient is also taking a beta blocker such as metoprolol. 5. Colace does not interact with glyburide. Page Ref: 617 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

35 ..

37) A patient with type 2 diabetes mellitus has been instructed on an eating plan where 65% of all daily calories are to be carbohydrates. The patient's daily caloric intake is to be 1600 calories. If each serving of carbohydrates is 15 grams and each gram is 4 kilocalories, how many servings of carbohydrates should the patient be instructed to consume each day? Record your answer rounding to the nearest whole number. Answer: 17 Explanation: First determine the total amount of carbohydrate calories permitted by multiplying 1600 × 65% = 1040. Then divide the total carbohydrate calories per day by 4 kilocalories or 1040/4 = 260 grams. Then divide the total number of carbohydrate grams by 15 or 260/15 = 17.3 or 17. Page Ref: 620 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

36 ..

38) The nurse is reviewing the actions that a patient with type 1 diabetes mellitus should take if mild hypoglycemia is experienced. What should the nurse include in this teaching? Select all that apply. 1. Test blood glucose 30 minutes after reaching a normal blood glucose level. 2. Ingest 4 ounces of fruit juice when mild hypoglycemia occurs. 3. Measure blood glucose 15 minutes after ingesting a carbohydrate source. 4. Add table sugar to 8 ounces of fruit juice when mild hypoglycemia occurs. 5. Ingest additional 15 grams of carbohydrate if blood glucose remains low after 15 minutes. Answer: 2, 3, 5 Explanation: 1. There is no specific recommendation as to when to reassess blood glucose level. 2. When mild hypoglycemia occurs, immediate treatment is necessary. People experiencing hypoglycemia should take about 15 grams of a rapid-acting sugar. This amount of sugar is found in 1/2 cup (4 ounces) of fruit juice. 3. After eating a carbohydrate source, the patient should wait 15 minutes and then monitor blood glucose level. 4. Adding sugar to the fruit sugar already in the juice could cause a rapid rise in blood glucose, with persistent hyperglycemia. 5. If the blood glucose remains low after 15 minutes, eat another 15 grams of carbohydrate. Page Ref: 604 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with diabetes mellitus.

37 ..

39) The nurse is caring for a patient experiencing diabetic ketoacidosis. What action should the nurse take when preparing this patient's insulin infusion? Select all that apply. 1. Attach insulin infusion to an intravenous pump. 2. Have one ampule of Dextrose 10% at the bedside. 3. Flush the tubing with the insulin solution before connecting. 4. Prepare an infusion of Dextrose 5% and 0.45% normal saline. 5. Discontinue the infusion after first dose of subcutaneous insulin. Answer: 1, 3, 5 Explanation: 1. Insulin infusions are always administered using an intravenous pump. 2. Dextrose 50 should be kept at the bedside in the event of a hypoglycemic reaction. 3. Flush the intravenous tubing with 50 mL of insulin mixed with normal saline solution to saturate binding sites on the tubing before administering the insulin to the patient. 4. Insulin infusions are diluted in 0.9% or 0.45% saline. 5. Do not discontinue the intravenous infusion until subcutaneous administration of insulin is resumed. Page Ref: 603 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 20.3 Differentiate the acute and chronic complications of DM and describe treatment plans for each. MNL Learning Outcome: 2. Consider intraprofessional care for patients with diabetes mellitus.

38 ..

40) The nurse notes that a patient with type 2 diabetes mellitus is not prescribed aspirin 81 mg as recommended for the prevention of cardiovascular complications. What information in the patient's health history should the nurse use to understand why this medication has not been prescribed for the patient? Select all that apply. 1. Patient receives a vitamin B12 injection every month. 2. Patient admitted for gastrointestinal bleeding 3 months ago. 3. Patient prescribed warfarin (Coumadin) 2.5 mg by mouth every day. 4. Patient treated for chronic alcoholism and liver cirrhosis the past year. 5. Patient develops a rash and urticaria when taking medications with sulfa. Answer: 2, 3, 4 Explanation: 1. Aspirin therapy is not contraindicated in individuals receiving vitamin B 12 injections. 2. Aspirin therapy is contraindicated in patients with recent gastrointestinal bleeding. 3. Aspirin therapy is contraindicated in patients on anticoagulation therapy. 4. Aspirin therapy is contraindicated in patients with active liver disease. 5. Aspirin therapy is not contraindicated in patients with an allergy to sulfa medications. Page Ref: 618 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 20.4 Outline the diagnostic tests used for screening, diagnosing, and monitoring DM and the use of insulin and oral hypoglycemic agents to treat patients with DM. MNL Learning Outcome: 2. Consider intraprofessional care for patients with diabetes mellitus.

39 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 21 Assessing the Gastrointestinal System 1) An adolescent patient plans to lose weight by eliminating all fat from the diet. Which action should the nurse take first? 1. Contact the physician. 2. Notify the patient's parents. 3. Refer the patient to a dietitian. 4. Discuss the role of fat in metabolism. Answer: 4 Explanation: 1. A discussion with the physician is likely warranted, but it can wait until after a discussion with the patient. 2. A discussion with the parents is likely warranted, but it can wait until after a discussion with the patient. 3. A referral from the physician is needed to contact the dietitian. 4. All individuals require some fat in the diet. It is important for the nurse to discuss this with the patient. The interaction will provide additional information concerning the patient's knowledge of a healthy diet. Page Ref: 636 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

1 ..

2) A patient with multiple skin lesions reports following a very-low-calorie diet to maintain weight loss. What should the nurse identify as the patient's priority problem? 1. Inadequate nutritional intake 2. Issues with activity 3. Tissue perfusion insufficiency 4. Risk for self-harm Answer: 1 Explanation: 1. A deficit of fats may cause excessive weight loss and skin lesions. 2. There is no evidence that the patient is having issues with activity. 3. The patient's skin lesions do not indicate a problem with tissue perfusion. 4. There is no evidence that the patient is at risk for self-harm. Page Ref: 646 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment. 3) A patient tells the nurse about taking large doses of vitamin A for skin health. What should the nurse respond to this patient? 1. "That is a great idea." 2. "That will not benefit your skin. You excrete high doses of vitamin A in your urine." 3. "You should take vitamin C to balance the large dose of A." 4. "Too much vitamin A can be toxic to your body." Answer: 4 Explanation: 1. This response supports a potentially harmful practice. 2. Excessive intake of fat-soluble vitamins is not managed by urinary excretion. 3. Vitamin C does not balance out excess intake of vitamin A. 4. Vitamin A is a fat-soluble vitamin. Excessive intake of fat-soluble vitamins results in toxicity. Page Ref: 636 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning 2 ..

Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system. 4) A patient is scheduled for a liver biopsy. What should the nurse include in this patient's preprocedure teaching? 1. Abstain from all food and fluids for at least 8 hours prior to the procedure. 2. Consume a low-fat diet 1-3 days prior to the procedure. 3. Complete blood tests prior to the procedure. 4. Restrict activity for 4-6 weeks after the procedure. Answer: 3 Explanation: 1. Food and fluids are withheld for 4-6 hours before the procedure. 2. Dietary changes before the test are not indicated. 3. The patient will require prothrombin time and platelet count prior to the procedure. 4. Activity will be limited for 1-2 weeks. Page Ref: 654 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

3 ..

5) The nurse is preparing to assess a patient's gastrointestinal system. What should the nurse say to gain the most information about this patient's elimination pattern? 1. "Are you having any bowel problems?" 2. "Have you had any recent difficulties with your stools?" 3. "Tell me about your usual bowel habits." 4. "Are your bowel movements normal?" Answer: 3 Explanation: 1. Questions that allow the patient to respond with a yes or no can limit communication and data gathering. 2. Questions that allow the patient to respond with a yes or no can limit communication and data gathering. 3. Open-ended questions provide the greatest amount of information. 4. Questions that allow the patient to respond with a yes or no can limit communication and data gathering. Page Ref: 641 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

4 ..

6) The nurse is preparing to examine a patient's abdomen. In which order should the nurse complete this examination? Place in order the steps of the process. Choice 1. Percussion Choice 2. Inspection Choice 3. Palpation Choice 4. Auscultation Answer: 2, 4, 1, 3 Explanation: Choice 1. Percussion in each quadrant is the third step. Choice 2. The sequencing of the assessment is important to obtain the maximum amount of information. Before touching the abdomen, the nurse should first inspect it for symmetry, contour, and general appearance. Choice 3. Palpation is the final step. It might result in discomfort, and should be completed last. Choice 4. Second, each quadrant of the abdomen should be auscultated for the presence of bowel sounds. Page Ref: 645-647 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

5 ..

7) The nurse determines that a patient's body mass index (BMI) is 22 kg/m2. Based on this finding, what should the nurse conclude? 1. BMI should be between 19 and 25 kg/m2. The patient's weight is within a healthful range. 2. The patient needs to lose weight for optimum health. 3. The patient is mildly obese. 4. The patient's BMI is below normal. Answer: 1 Explanation: 1. The patient's BMI is within normal limits. 2. The patient does not need to lose weight. 3. The patient is not mildly obese. Obesity is indicated by a body mass index of 30 kg/m2 or greater. 4. A BMI under 19 would be below normal. Page Ref: 644 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

6 ..

8) The nurse is teaching a group of older adults about expected changes in dental health related to aging. Which statement by one of the older adults indicates that teaching has been effective? 1. "Tooth enamel is more pliable." 2. "The loss of bone density with aging results in tooth decay and breakage." 3. "Increases in saliva production increase exposure of the tooth's enamel to corrosive agents." 4. "Metabolic changes in aging contribute to dental destruction." Answer: 2 Explanation: 1. Tooth enamel becomes more brittle with aging. 2. Changes in bone health related to aging increase the risk of tooth loss and teeth fractures. 3. Saliva production decreases with aging. 4. Metabolic changes do not cause dental decay or fractures. Page Ref: 655 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.4 Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

7 ..

9) A patient with a 2-month history of diarrhea is prescribed a diagnostic test that uses a narrow x-ray beam to provide a 360-degree view of abdominal structures. For which diagnostic test should the nurse prepare the patient? 1. Liver biopsy 2. Cholecystography 3. Gastric emptying study 4. Computed tomography Answer: 4 Explanation: 1. A liver biopsy takes a piece of the liver to assess for the presence of pathology. 2. A cholecystography assesses for gallbladder stones or tumors. 3. Gastric emptying studies provide information about the body's ability to empty the stomach. 4. The computed tomography (CT) scan produces a narrow x-ray beam that examines the body sections from 360 degrees. Page Ref: 653 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

8 ..

10) The nurse is preparing to assess a young adult female with right-upper-quadrant abdominal pain. Which question should the nurse ask when performing this assessment? 1. "Does the pain worsen when you inhale?" 2. "Do you have a history of diabetes?" 3. "When you eat, do you experience any nausea?" 4. "Have your periods been normal?" Answer: 1 Explanation: 1. The patient with inflammation of the gallbladder feels sharp pain on inspiration and stops inspiring. 2. Diabetes does not cause right-upper-quadrant abdominal pain. 3. Information about eating and nausea would not be helpful in determining the cause of the patient's pain. 4. Menstruation does not cause right-upper-quadrant abdominal pain. Page Ref: 647 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

9 ..

11) While conducting an abdominal assessment, the nurse notes dullness on percussion when the patient turns from the supine position to the right side. How should the nurse interpret this finding? 1. The patient is exhibiting normal findings. 2. The patient is exhibiting signs consistent with ascites. 3. The patient is exhibiting signs consistent with a bowel obstruction. 4. The patient is exhibiting signs consistent with hepatomegaly. Answer: 2 Explanation: 1. This is not a normal finding. 2. The patient is exhibiting evidence of ascites. The dullness on percussion is present with position changes. 3. Percussion of a side-lying patient is not used to assess for a bowel obstruction. 4. Percussion of a side-lying patient is not used to assess for hepatomegaly. Page Ref: 646 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

10 ..

12) The nurse is planning the diet for a patient scheduled to have a barium enema in 2 days. What kind of diet should the nurse plan for the next 48 hours? 1. General diet 2. Full diet today, clear liquids tomorrow 3. Full liquids today, nothing by mouth tomorrow 4. Clear liquids both today and tomorrow Answer: 2 Explanation: 1. A general diet would not adequately prepare the patient's bowel for the examination. 2. Prior to undergoing a barium enema, patients are asked to follow a clear liquid diet for 24 hours before the examination. 3. A full liquid diet would not adequately prepare the patient's bowel for the examination. 4. Clear liquids are needed for only 1 day before the examination. Page Ref: 651 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

11 ..

13) A patient is recovering from a sigmoidoscopy with removal of a benign polyp. What should the nurse include in this patient's discharge instructions? 1. Contact the primary healthcare provider if experiencing large amounts of flatus. 2. Avoid heavy lifting for 2 weeks after procedure. 3. Report abdominal pain, fever, or chills. 4. Beginning the evening after the procedure, eat foods high in fiber. Answer: 3 Explanation: 1. Flatus after the procedure is anticipated and does not warrant contacting the physician. 2. Heavy lifting is to be avoided for only 1 week. 3. The patient who has had a sigmoidoscopy must report potential complications such as abdominal pain, fever, or chills. 4. High-fiber foods are to be avoided for 1-2 days. Page Ref: 652 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

12 ..

14) An 85-year-old patient is concerned about the loss of sensation of the need to defecate. How should the nurse respond? 1. "This is a normal part of aging due to slowed intestinal absorption." 2. "As you age, the rectum loses tone, and there is a reduced sensation of the need to defecate." 3. "Have you had a colonoscopy in the past year to evaluate the condition?" 4. "Reduced vitamin K absorption is associated with this condition." Answer: 2 Explanation: 1. Intestinal absorption does slow with aging but is not responsible for the concerns raised by the patient. 2. The loss of muscle tone within the internal sphincter is responsible for the patient's clinical manifestations. 3. Asking about a colonoscopy does not address the patient's concern. 4. Vitamin K absorption is reduced with aging but is not responsible for the changes being reported. Page Ref: 655 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.4 Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

13 ..

15) The nurse is teaching a patient scheduled for a colonoscopy. Which patient statement indicates a need for further teaching? 1. "The procedure will only take about an hour." 2. "It might be quite painful." 3. "I will likely have medications that will make me drowsy during the test." 4. "The physician might take tissue samples for further analysis." Answer: 2 Explanation: 1. A colonoscopy takes approximately 1 hour to perform. 2. The colonoscopy is not painful, as patients are given sedating medications. 3. Patients undergoing colonoscopies are given sedating medications. 4. The physician may take a small tissue sample during the procedure. Page Ref: 651 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

14 ..

16) The nurse is planning care for a patient scheduled for a barium enema the next morning. What should be included in the plan of care? 1. Enemas after the procedure 2. Full-liquid diet for 24 hours before the procedure 3. Positioning the patient on the right side during the procedure 4. Nothing by mouth for 8-12 hours prior to the procedure Answer: 4 Explanation: 1. Enemas or laxatives are administered before the procedure, not after. 2. A full-liquid diet is recommended for 2 days before the procedure. 3. The patient will be positioned on the left side during the procedure. 4. Preprocedural care for a colonoscopy requires that the patient take nothing by mouth for 8 hours. Page Ref: 649 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

15 ..

17) During the admission assessment, the nurse learns that a patient is menstruating. Which prescribed diagnostic test could be impacted by this finding? 1. Small bowel series 2. Barium enema 3. Stool culture 4. Colonoscopy Answer: 3 Explanation: 1. The small bowel series will not be impacted by menstrual bleeding. 2. The barium enema will not be impacted by menstrual bleeding. 3. For a stool culture the stool is collected immediately after defecation. With vaginal bleeding, it is possible that menstrual blood could mix with the stool during defecation. 4. The colonoscopy will not be impacted by menstrual bleeding. Page Ref: 652 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

16 ..

18) An older patient does not understand why the hemoglobin level is low despite eating a healthy diet. How should the nurse respond? 1. "You might not be eating as well as you think." 2. "This happens as you get older." 3. "As we age, the amount of iron absorbed by our body decreases." 4. "Menopause is responsible for these changes." Answer: 3 Explanation: 1. This response is potentially argumentative and does not provide education regarding the underlying cause of the problem. 2. The iron deficiency is indirectly related to aging, but it is the responsibility of the nurse to provide as much information as possible. 3. A reduction in the absorption rate of ingested iron is a normal part of aging. Dietary modifications might be indicated to counteract life-span-related changes. 4. The patient is likely well past menopause, and blaming this life event for the difficulty being experienced does not fulfill the nurse's responsibility. Page Ref: 655 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 21.4 Differentiate considerations for assessing the GI system of older adults, veterans, and individuals in the LGBTQI population. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

17 ..

19) When assessing a patient's abdomen, the nurse notes frequent pulsations in the epigastric region. What action should the nurse take? 1. Document the findings as hyperactive bowel sounds. 2. Review the patient's medical records for signs and symptoms of cirrhosis, which may indicate ascites. 3. Note the time when the patient last voided. 4. Notify the physician about the findings. Answer: 4 Explanation: 1. Bowel sounds are audible, not visible. 2. Ascites is the collection of fluid. 3. Bladder distention is not manifested as pulsations. 4. Patients having an aortic aneurysm present with increased pulsations. This should be reported. Page Ref: 645 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

18 ..

20) The nurse is conducting an abdominal assessment. Which finding should the nurse realize is most likely related to a diagnosis of acute diverticulitis? 1. Lower-right-quadrant pain 2. Lower-left-quadrant pain 3. Upper-middle abdominal pain 4. Back pain and tenderness Answer: 2 Explanation: 1. Lower-right-quadrant pain is noted with appendicitis. 2. Diverticulitis in the acute stage presents with changes in elimination and lower-left abdominal pain. 3. Upper-middle abdominal pain is seen with acute pancreatitis. 4. Back pain and tenderness are manifestations most commonly seen with kidney disorders. Page Ref: 647 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

19 ..

21) A patient reports epigastric abdominal pain, nausea, and vomiting. The serum amylase level is 450 units/dL. For which health problem should the nurse plan care? 1. Gastritis 2. Malnutrition 3. Pancreatitis 4. Diverticulitis Answer: 3 Explanation: 1. The serum amylase level is not elevated in gastritis. 2. Epigastric pain and an elevated serum amylase level are not manifestations of malnutrition. 3. Epigastric pain and an elevated serum amylase level are manifestations of pancreatitis. 4. Epigastric pain and an elevated serum amylase level are not manifestations of diverticulitis. Page Ref: 653 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

20 ..

22) The nurse determines that a patient has a scaphoid abdomen. Which health problem should the nurse suspect the patient is experiencing? 1. Type 2 diabetes mellitus 2. Crohn disease 3. Malnutrition 4. Diverticulosis Answer: 3 Explanation: 1. A scaphoid abdomen is not associated with type 2 diabetes mellitus. 2. A scaphoid abdomen is not associated with Crohn disease. 3. A scaphoid abdomen is one that appears sunken. It is associated with malnutrition. 4. A scaphoid abdomen is not associated with diverticulitis. Page Ref: 645 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

21 ..

23) The nurse is teaching a patient about a scheduled small bowel series. Which statement by the patient indicates that further teaching is required? 1. "It is normal to experience constipation for a few days after the procedure." 2. "I will need to increase my fluid intake the first few days after the procedure." 3. "I might have a laxative prescribed after the procedure." 4. "The barium will be inserted through my rectum." Answer: 1 Explanation: 1. The barium instilled during the procedure must be evacuated after the procedure. The patient will experience white, chalky stools for the first few days. 2. An increase in fluid intake will facilitate the stool's evacuation. 3. Laxative use will facilitate the stool's evacuation. 4. Barium in a small bowel series is administered orally, into the bowel via an endoscope, or through a weighted tube. Page Ref: 651 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

22 ..

24) The nurse is planning teaching for a patient scheduled for an abdominal ultrasound. How should the nurse instruct the patient to prepare for this test? 1. "Advise the technician if you suspect you are pregnant." 2. "Drink 1 to 2 quarts of water 1 hour before the procedure." 3. "Do not eat anything 8 to 12 hours before the procedure." 4. "Take a laxative the evening before the procedure." Answer: 3 Explanation: 1. This test is not contraindicated in pregnancy. 2. The patient will need to avoid oral intake 8-12 hours before the procedure. 3. The patient will need to avoid oral intake 8-12 hours before the procedure. 4. Laxative use is not needed for this procedure. Page Ref: 651 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

23 ..

25) A patient complains of constipation. Which question should the nurse ask to learn more about the problem? 1. "Are you taking any narcotic medication?" 2. "Have you been taking over-the-counter pain relievers?" 3. "Have you been taking over-the-counter sleep aids?" 4. "Are you taking oral contraceptives?" Answer: 1 Explanation: 1. Narcotics may cause constipation. 2. Over-the-counter pain relievers do not affect elimination patterns. 3. Over-the-counter medications for insomnia do not affect elimination patterns. 4. Oral contraceptives do not affect elimination patterns. Page Ref: 642 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

24 ..

26) The nurse is planning care for a patient who has a moderate daily protein restriction. Which meal choice would be most appropriate for this patient? 1. Peanut butter sandwich and apple slices 2. Bean soup and spinach salad 3. Salmon fillet and asparagus 4. Fried rice and fresh strawberries Answer: 3 Explanation: 1. Legumes such as peanuts contain incomplete proteins. These sources are low in or lack one or more of the amino acids essential for building complete proteins. 2. Legumes and vegetables contain incomplete proteins. These sources are low in or lack one or more of the amino acids essential for building complete proteins. 3. Because the patient's protein intake is limited, it is important that the protein choices are complete proteins. Complete proteins are found in animal products such as eggs, milk, milk products, and meat. They contain the greatest amount of amino acids and meet the body's requirements for tissue growth and maintenance. 4. Grains and vegetables contain incomplete proteins. These sources are low in or lack one or more of the amino acids essential for building complete proteins. Page Ref: 636 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

25 ..

27) The nurse is planning a class on nutrition for middle-school students. Which data points should be included in the presentation? Select all that apply. 1. Sufficient dietary fats help people absorb vitamins. 2. Cholesterol is needed for proper hormonal function. 3. Fat tissue helps insulate the internal organs. 4. Vitamin K is formed by the action of ultraviolet radiation on the skin. 5. Vitamin D is synthesized by bacteria in the intestine. Answer: 1, 2, 3 Explanation: 1. Dietary fat is needed to absorb fat-soluble vitamins. 2. Cholesterol is needed for proper hormonal function. 3. Fat tissue helps insulate the internal organs. 4. Vitamin D, not K, is formed by the action of ultraviolet radiation on the skin. 5. Vitamin K, not D, is synthesized by bacteria in the intestine. Page Ref: 636 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

26 ..

28) The home health nurse is teaching a patient about vitamin requirements. Which statement indicates that the patient requires additional teaching? 1. "I will follow the National Academy of Sciences recommendations for daily intake of vitamins." 2. "I might need more or fewer vitamins than someone else, based on my lifestyle." 3. "Evidence-based practice sometimes changes the recommended amount of a specific vitamin." 4. "Vitamins obtained through food are superior to those obtained through tablets and pills." Answer: 4 Explanation: 1. The National Academy of Sciences does publish the results of research and make recommendations regarding minimum daily vitamin intake. 2. It is true that vitamin requirements are not the same for all people. 3. Evidence-based practice sometimes results in changes in recommended doses of vitamins. 4. There is no current data to support a preference for one source of vitamins over another. Page Ref: 636 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

27 ..

29) A patient asks if going on an all-fruit diet is a good decision. How should the nurse respond? Select all that apply. 1. "Fruit is natural and a good source of carbohydrates." 2. "Fruit is a good source of carbohydrates but a poor source of fats and protein." 3. "Fruit supplies many important vitamins but can cause muscle breakdown." 4. "Incorporating fruit with complete sources of protein and healthful fats provides complete nutrition." 5. "A fruit-based diet will reduce your risk of developing diabetes mellitus." Answer: 2, 3, 4 Explanation: 1. Fruit is a good source of carbohydrates, but a patient who eats only fruit will likely not be able to ingest enough protein and fat to maintain health. 2. Fruit is a good source of carbohydrates, but a patient who eats only fruit will likely not be able to ingest enough protein and fat to maintain health. 3. Fruit is a good source of vitamins but can cause muscle breakdown. 4. Incorporating fruit into a diet that includes healthful proteins and fats is the best way to assure adequate nutrition. 5. There is no evidence that a fruit-based diet protects patients from diabetes mellitus. Page Ref: 635-636 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.1 Outline the nutrients absorbed in the gastrointestinal (GI) system. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

28 ..

30) The nurse is teaching a group of 6-year-olds about the digestive system. Which statement by a child indicates that teaching has been effective? Select all that apply. 1. "Grown-ups have 28 teeth." 2. "Spit helps you taste your food." 3. "Food starts breaking down in the stomach." 4. "It's like a tube. Food I need goes in one end. What I don't need comes out the other." 5. "The food moves through the tube in waves, like a snake eating a mouse." Answer: 2, 4, 5 Explanation: 1. Adults have 32 teeth. 2. Saliva begins the process of breaking down food and does help one taste food. 3. Food begins to digest in the mouth due to the action of enzymes such as amylase. 4. The GI tract is like a tube in which food enters one end and waste products exit the other end. 5. Food is propelled through the tube in peristaltic waves, which a child might equate to the motion of a snake eating a mouse. Page Ref: 637-639 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.2 Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

29 ..

31) The nurse reviews the functions of the gastrointestinal system for a patient with celiac disease. Which statement by the patient indicates that teaching has been effective? 1. "The stomach begins the process of absorbing nutrients." 2. "The stomach turns food into liquid so it can be digested." 3. "The stomach begins the digestion of carbohydrates." 4. "The stomach secretes sulfuric acid." Answer: 2 Explanation: 1. The process of absorption begins in the small intestine. 2. The stomach mixes the food with gastric juices into a thick fluid called chyme. 3. The start of carbohydrate digestion occurs in the mouth. 4. The stomach secretes hydrochloride, not sulfuric acid. Page Ref: 638 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.2 Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

30 ..

32) The nurse is preparing to conduct a physical assessment of a patient with obesity. What equipment should the nurse have available for this assessment? Select all that apply. 1. Scale 2. Skinfold calipers 3. Calculator 4. Glucose meter 5. Supplies for blood draw Answer: 1, 2, 3 Explanation: 1. The nurse will require a scale to weigh the patient. 2. The nurse will require skinfold calipers to assess the patient's body fat. 3. The nurse will require a calculator to help determine the patient's body mass index and ideal body weight. 4. A glucose meter may be used in the future but is not needed during the initial assessment. 5. Supplies for a blood draw may be needed eventually but are not indicated for the initial assessment. Page Ref: 642 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

31 ..

33) The nurse is reviewing data collected from a group of patients. Which patient has a normal waist-to-hip ratio? 1. Female patient, waist 29 inches, hips 35 inches 2. Female patient, waist 29 inches, hips 36 inches 3. Male patient, waist 37 inches, hips 36 inches 4. Male patient, waist 40 inches, hips 41 inches Answer: 4 Explanation: 1. This patient has a waist-to-hip ratio of 0.83. A healthful ratio for a female is 0.8 or less. 2. This patient has a waist-to-hip ratio of 0.81. A healthful ratio for a female is 0.8 or less. 3. This patient has a waist-to-hip ratio of 1.03. A healthful ratio for a male is 1.0 or less. 4. This patient has a waist-to-hip ratio of 0.98. A healthful ratio for a male is 1.0 or less. Page Ref: 644 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

32 ..

34) A patient whose diet consists of processed food from fast-food restaurants has painful lesions at the corners of the mouth. How should the nurse document this finding? 1. Glossitis 2. Gingivitis 3. Cheilosis 4. Leukoplakia Answer: 3 Explanation: 1. Glossitis refers to an inflamed tongue. 2. Gingivitis refers to inflamed gums. 3. Cheilosis is the term for painful lesions at the corners of the mouth and is seen with riboflavin and/or niacin deficiency. 4. Leukoplakia refers to white patches inside the mouth. Page Ref: 644 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

33 ..

35) The nurse is assessing a patient who uses chewing tobacco. Which data would be most important for the nurse to obtain? 1. The patient denies shortness of breath. 2. The patient has no leukoplakia. 3. The patient has no glossitis. 4. The patient has no signs of candidiasis. Answer: 2 Explanation: 1. Chewing tobacco places the patient at risk for oral carcinoma, not lung cancer. 2. Leukoplakia is the term for small white patches, which may be a sign of a premalignant condition. 3. Glossitis is a bright red tongue. 4. Candidiasis is not associated with oral carcinoma. Page Ref: 644 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

34 ..

36) The nurse is preparing to assess a patient with a suspected abdominal mass. Which technique should the nurse use for this assessment? Select all that apply. 1. Shine a light source across the abdomen. 2. Inspect by standing beside the patient. 3. Inspect from the patient's right side. 4. Inspect for symmetry and visible peristalsis. 5. Ask the patient to deep-breathe and inspect. Answer: 1, 3, 4, 5 Explanation: 1. The nurse should inspect the abdomen under a good light source that is shining across the abdomen. 2. The nurse should not stand beside the patient. 3. Inspection is performed by sitting by the patient's right side, where the nurse is in the best position to note conditions and deviations from normal. 4. The nurse should inspect the abdomen for symmetry and visible peristalsis. 5. If masses are detected, the nurse should ask the patient to take a deep breath. This reduces the size of the abdominal cavity and makes any abnormality more visible. Page Ref: 643 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

35 ..

37) The nurse is preparing to percuss the abdomen of a patient. Which information indicates that the nurse might need assistance with this assessment? 1. The nurse plans to use a systematic approach for the assessment. 2. The nurse anticipates hearing tympany over stool-filled intestines. 3. The nurse anticipates hearing dullness over the liver. 4. The nurse plans to percuss the spleen, liver, and kidneys. Answer: 2 Explanation: 1. The nurse should percuss several areas within each quadrant of the abdomen, using a systematic path. 2. The nurse should anticipate hearing tympany over air-filled organs such as gas-filled intestines. Intestines that are stool-filled will sound dull. 3. The nurse should anticipate hearing a dull sound over the liver. 4. The nurse should percuss over the spleen, kidneys, and liver. Page Ref: 645 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

36 ..

38) The nurse is reviewing data within a patient's health history. Which factor in the history should the nurse recognize as related to the development of familial adenomatous polyposis? 1. The patient eats a diet high in red meat. 2. The patient has never had the recommended screening colonoscopy. 3. The patient's grandfather died of colon cancer. 4. The patient had a basal cell skin cancer removed 2 year ago. Answer: 3 Explanation: 1. A high intake of red meat does not predispose the patient to familial adenomatous polyposis. 2. Not completing a screening colonoscopy does not predispose the patient to familial adenomatous polyposis. 3. Familial adenomatous polyposis (FAP) is an inherited disorder characterized by progressive development of colorectal adenomas. Unless treated, colorectal cancer inevitably occurs by the fourth or fifth decade of life. 4. Basal cell skin cancer does not predispose the patient to familial adenomatous polyposis. Page Ref: 641 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

37 ..

39) The nurse is conducting an educational session for patients who have a diagnosis of Crohn disease. Fifty patients with the disorder are in attendance. Statistically, how many of these patients have a form of Crohn disease that is familial in origin? Record your answer rounding to the nearest whole number. Answer: 10 Explanation: Statistically, 20% of patients with Crohn disease have a familial form of the disorder. 50 × 20% = 10 participants. Page Ref: 641 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the gastrointestinal system.

38 ..

40) The nurse is instructing a patient newly diagnosed with celiac disease. For which food choices should the nurse provide follow-up teaching? 1. Spinach salad and corn 2. Beefsteak and green beans 3. Whole-wheat toast and baked chicken 4. Apple slices and tuna salad Answer: 3 Explanation: 1. This is a healthy choice for this patient because these foods do not contain gluten. 2. This is a healthy choice for this patient because these foods do not contain gluten. 3. Whole-wheat toast is not a healthful choice for this patient. If people with celiac disease eat certain types of proteins (glutens, found in wheat, barley, rye, and oats), an autoimmune response causes damage to the small intestine, and nutrients are not absorbed. 4. This is a healthy choice for this patient because these foods do not contain gluten. Page Ref: 641 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

39 ..

41) A patient of Jewish heritage is experiencing body aches and fatigue. The nurse notes that the patient's skin appears pale and yellow-tinged. What nutritional health problem should the nurse suspect is occurring in this patient? 1. Tangier disease 2. Hypercholesterolemia 3. Gaucher disease 4. Lynch Syndrome Answer: 3 Explanation: 1. Tangier disease is a disease of cholesterol transport characterized by orange tonsils, very low levels of high-density lipoprotein, and an enlarged liver and spleen. 2. These findings are not characteristic of hypercholesterolemia. 3. This patient's findings are most consistent with Gaucher disease, which is more common in descendants of Jewish people from Eastern Europe. The disorder results in lack of an enzyme to break down fats, which accumulate in the liver, spleen, and bone marrow, causing pain, fatigue, jaundice, bone damage, anemia, and even death. 4. Lynch syndrome is a type of inherited cancer of the GI system, especially the colon and rectum. Colon polyps occur at an early age and are more likely to become malignant. Page Ref: 641 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

40 ..

42) The nurse notes that a patient's stool specimen is watery and diarrhea-like. Which health problem should the nurse suspect is occurring in this patient? Select all that apply. 1. Malabsorption 2. Antibiotic reaction 3. Lactose intolerance 4. Irritable bowel syndrome 5. Ingestion of spoiled food Answer: 1, 3, 4, 5 Explanation: 1. Watery, diarrhea stools appear with malabsorption problems. 2. Watery, diarrhea stools are not associated with antibiotic reactions. 3. Watery, diarrhea stools appear with lactose intolerance. 4. Watery, diarrhea stools appear with irritable bowel syndrome. 5. Watery, diarrhea stools appear with ingestion of spoiled foods. Page Ref: 648 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

41 ..

43) The nurse is caring for a patient with liver disease. What nutritional issue should the nurse expect this patient to exhibit? Select all that apply. 1. Alteration in fat metabolism 2. Increase in glucose utilization 3. Reduction in fat-soluble vitamins 4. Lower amount of bile being stored 5. Change in production of red blood cells Answer: 1, 3, 5 Explanation: 1. The liver synthesizes fats from carbohydrates and proteins to be used for energy or stored as adipose tissue. 2. The liver releases glucose during times of hypoglycemia. 3. The liver stores fat-soluble vitamins. 4. The liver secretes but does not store bile. 5. The liver stores iron as ferritin, which is released as needed for the production of red blood cells. Page Ref: 640 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 21.2 Describe the anatomy, physiology, and functions of the GI system and identify abnormal findings that may indicate impairment of the GI system. MNL Learning Outcome: 3. Interpret abnormal findings of the gastrointestinal system collected during assessment.

42 ..

44) A patient is being evaluated for liver disease. Which laboratory tests should the nurse expect to be prescribed for this patient? Select all that apply. 1. Serum sodium 2. Serum potassium 3. Alkaline phosphatase 4. Alanine aminotransferase 5. Aspartate aminotransferase Answer: 1 Explanation: 1. Serum sodium is not a laboratory test specific for liver function. 2. Serum potassium is not a laboratory test specific for liver function. 3. Alkaline phosphatase is a laboratory test specific for liver function. Normal levels range from 42 to 136 units/L. 4. Alanine aminotransferase is a laboratory test specific for liver function. Normal levels range from 10 to 35 units/L. 5. Aspartate aminotransferase is a laboratory test specific for liver function. Normal levels range from 8 to 38 units/L. Page Ref: 654 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 21.3 Outline the components of the assessment of the GI system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the gastrointestinal system.

43 ..

45) A middle-aged patient with minimal health problems asks what can be done to prevent gaining weight with aging. What should the nurse instruct this patient? Select all that apply. 1. Drink adequate fluids. 2. Avoid processed foods. 3. Avoid foods high in fat. 4. Maintain the same amount of caloric intake. 5. Eat a well-balanced diet with fruit and vegetables. Answer: 1, 2, 3, 5 Explanation: 1. To prevent weight gain with aging, the patient should be instructed to drink adequate fluids. 2. To prevent weight gain with aging, the patient should be instructed to avoid processed foods. 3. To prevent weight gain with aging, the patient should be instructed to avoid foods high in fat. 4. To prevent weight gain with aging, the patient should be instructed to gradually reduce the amount of calories consumed. 5. To prevent weight gain with aging, the patient should be instructed to eat a well-balanced diet with fruits and vegetables. Page Ref: 656 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 21.5 Summarize topics that nurses teach to promote a healthy GI system across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

44 ..

46) The nurse is preparing a teaching tool for a community health fair. Which should the nurse include on a list to avoid to reduce the risk of developing cancer of the gastrointestinal system? Select all that apply. 1. Smoking 2. Red meat 3. Canned foods 4. Alcohol intake 5. Excess activity Answer: 1, 3 Explanation: 1. Smoking has been linked to oral and esophageal cancer. 2. Red meat has not been linked to any specific gastrointestinal cancer. 3. Canned foods have not been linked to any specific gastrointestinal cancer. 4. Alcohol intake has been linked to oral, esophageal, and liver cancer. 5. Excess activity has not been linked to any specific gastrointestinal cancer. Page Ref: 656 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 21.5 Summarize topics that nurses teach to promote a healthy GI system across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the gastrointestinal system collected during assessment and health promotion activities to support the health of this body system.

45 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 22 Nursing Care of Patients with Nutritional Disorders 1) The nurse is caring for an adolescent with anorexia nervosa. What should the nurse include in this patient's plan of care? 1. Provide a variety of cold or room-temperature foods. 2. Serve the patient three balanced meals per day. 3. Discuss weight-gain needs with the patient. 4. Observe the patient's activities for 15 minutes after eating. Answer: 1 Explanation: 1. Cold or room-temperature foods are often more appealing to patients with anorexia nervosa. 2. Three meals daily could be overwhelming in size to the patient. Smaller, more frequent offerings will be better received by the patient. 3. A focus on gaining weight will promote fixation on pounds instead of health with this population. 4. A patient diagnosed with anorexia will have a greater benefit with discussions relating to caloric intake instead of just observing the patient. Page Ref: 686 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

1 ..

2) A patient diagnosed with obesity asks about the appetite suppressant phentermine to assist with a weight loss program. Which information in the patient's health history might restrict the patient's ability to take this medication? 1. Frequent use of alcohol 2. History of narcolepsy 3. A family history of thrombophlebitis 4. A body mass index of 31 kg/m2 Answer: 1 Explanation: 1. Alcohol use or abuse can be a contraindication for this medication. 2. The medication could cause insomnia but is not contraindicated for narcolepsy. 3. A patient's personal history for the development of cardiovascular problems could indicate an inability to take the medication. The choice regarding the family's health history is not applicable. 4. Phentermine is indicated for body mass index greater than 30 kg/m2. Page Ref: 664 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

2 ..

3) After following a structured diet, a patient diagnosed with diabetes mellitus is surprised to learn that blood glucose levels have decreased and oral medications are no longer required. What explanation regarding the impact of diet on diabetes management should the nurse give the patient? 1. Less body mass means less insulin is needed to maintain constant glucose levels. 2. Body mass reduces cellular resistance to insulin. 3. Reduced dietary intake of carbohydrates is responsible for the weight loss. 4. Reduced dietary intake results in a reduced need for insulin. Answer: 1 Explanation: 1. Insulin is needed by the body cells to facilitate glucose transport across cell walls. The greater the body's mass, the increase in likelihood the body's cells will become resistant to insulin. This will result in type 2 diabetes. 2. The more mass in the body, the greater the resistance of the body's cells to insulin. 3. The patient has reduced the amount of carbohydrates eaten to lose weight, but this response does not explain the patient's surprise in learning about the change in medication needs. 4. The reduction in size has resulted in a lower body glucose level in response. Page Ref: 662 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; PracticeKnow-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

3 ..

4) The nurse is planning care for a patient with anorexia nervosa. Which problem should the nurse identify as a priority for this patient? 1. Inadequate oral intake 2. Feelings of adequacy 3. Loss of control 4. Skewed opinion of appearance Answer: 1 Explanation: 1. An inadequate oral intake negatively impacts all physiological processes. This is the priority for the patient at this time. 2. The patient's psychological problems can be addressed after physiological issues are stabilized. 3. The patient's psychological problems can be addressed after physiological issues are stabilized. 4. The patient's psychological problems can be addressed after physiological issues are stabilized. Page Ref: 682-683 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

4 ..

5) A patient reports often eating excessive amounts of food when alone and when not hungry, and has intense feelings of self-disgust afterward. Which health problem is this patient at risk for developing? 1. Type 2 diabetes mellitus 2. Type 1 diabetes mellitus 3. Dehydration 4. Electrolyte imbalances Answer: 1 Explanation: 1. The patient is demonstrating a binge-eating disorder. The excessive eating eventually will result in weight gain. Individuals with a body mass index greater than recommended are at an increased risk for the development of type 2 diabetes mellitus. 2. Type 1 diabetes mellitus is most often seen in children. Individuals who have type 1 diabetes mellitus are usually underweight. 3. Dehydration is a complication of anorexia nervosa and bulimia nervosa. 4. Electrolyte imbalances are complications of anorexia nervosa and bulimia nervosa. Page Ref: 683 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

5 ..

6) An adolescent is reported being interested in losing weight and measures weight several times a day, but at times ingests large amounts of food. What should the nurse suspect is occurring with this patient? 1. Bulimia nervosa 2. Early-onset anorexia nervosa 3. Binge-eating disorder 4. Metabolic disorder Answer: 1 Explanation: 1. Bulimia nervosa is a disorder in which patients eat large quantities of foods and then purge themselves by means of vomiting. Laxatives also may be employed. 2. Anorexia nervosa patients display behaviors in which intake is avoided and excessive exercise rituals are initiated. 3. Patients with binge-eating disorders will eat large amounts of food. They are often overweight. 4. There is no evidence to support the patient having a metabolic disorder. Page Ref: 683 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

6 ..

7) The nurse teaches a patient about the medication orlistat (Xenical). Which patient statement indicates the need for additional teaching? 1. "I should take this medication 30 minutes before eating." 2. "This medication will reduce the amount of fat my body absorbs." 3. "I will need to take supplements of vitamins A, D, E, and K daily." 4. "A low-calorie diet will need to be followed." Answer: 1 Explanation: 1. The medication must be taken at mealtime or within the first hour of eating. 2. It is used to reduce the amount of fat absorbed from dietary intake. 3. Fat-soluble vitamins will be excreted, and must be replaced by supplements. 4. To maximize results, the patient must incorporate a low-calorie, low-fat diet into the daily routine. Page Ref: 664 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

7 ..

8) The nurse is helping a patient identify ways to adhere to a weight reduction plan. What should the nurse suggest to help this patient? 1. Set aside small nonfood rewards when you meet a goal. 2. Eat alone to reduce outside distractions. 3. Drink water or a diet beverage after eating to promote feelings of fullness. 4. Allow at least 45 minutes to 1 hour to promote full enjoyment of a meal. Answer: 1 Explanation: 1. When dieting, a small nonfood reward can serve as an incentive for working toward a goal. 2. Eating is a social activity. Talking with others during mealtime promotes involvement. 3. Drinking a beverage before eating promotes feelings of fullness and reduces intake at mealtime. 4. A meal should be slated to last only 20 minutes. Eating longer can promote eating more. Page Ref: 666 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Behavioral Interventions Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

8 ..

9) A patient planning to begin a weight loss diet asks the nurse for suggestions as to how to balance eating. What information should the nurse provide to the patient? 1. The diet should reduce calories to 1000‒1600 per day, with less than 10% of the total calories coming from fat. 2. The diet should be between 750 and 1000 calories per day, with less than 15% of the total calories coming from fat. 3. The diet should simply cut 500 calories per day from the normal intake. 4. The best diet will be between 1250 and 1500 calories per day, with 15% of the calories being sources of protein. Answer: 1 Explanation: 1. The best diet is a balance of all nutrients. Ideally, it should consist of 1000‒1600 calories per day and consist of no more than 10% fat. 2. A diet of 750 to 1000 calories per day is too rigid and could lead to physiologic health problems. 3. Cutting 500 calories per day from the normal intake could also be too rigid for the patient. Excessive calorie restrictions can lead to failure to follow the prescribed diet, feelings of guilt, and overeating. 4. Consuming a diet of 1250 to 1500 calories per day may not be enough to achieve weight loss. Page Ref: 666 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

9 ..

10) A patient desiring to begin a very-low-calorie diet (VLCD) for rapid weight reduction is concerned about the safety of the diet. What information should the nurse provide to the patient? 1. VLCDs are not recommended for people over age 50. 2. VLCDs result in significant losses of muscle mass in response to the protein restriction. 3. VLCDs are safe for patients who have a lower body mass index and need to lose a small amount of weight rapidly. 4. VLCDs are safest for middle-aged and senior patients. Answer: 1 Explanation: 1. Very-low-calorie diets (VLCDs) are indicated for patients having elevated body mass indexes greater than 30 kg/m2. VLCD may not be appropriate for use in people over age 50 due to normal loss of lean body mass and adverse effects such as fatigue, constipation, nausea, diarrhea, and gallstone formation. 2. A very-low-calorie diet (VLCD) is a protein-sparing modified fast (450 kcal/day) under close medical supervision and results in rapid weight loss while maintaining lean body mass. 3. Very-low-calorie diets (VLCDs) are indicated for patients having elevated body mass indexes greater than 30 kg/m2. 4. VLCD may not be appropriate for use in people over age 50 due to normal loss of lean body mass and adverse effects such as fatigue, constipation, nausea, diarrhea, and gallstone formation. Page Ref: 665-666 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

10 ..

11) A patient who is 5 feet 5 inches tall and weighs 144 lbs. asks the nurse if this is obesity. How should the nurse respond to this patient? 1. "You are a normal weight for your height." 2. "Yes, you are slightly obese for your height." 3. "You are slightly overweight." 4. "You are moderately obese." Answer: 1 Explanation: 1. BMI is calculated by dividing the weight (in kilograms) by the height in meters squared (m2). Utilizing the body mass index table, the patient has a body mass index of 24 kg/m2. A body mass index greater than 25 kg/m2 is considered overweight. 2. The patient is not slightly obese. 3. The patient is not slightly overweight. 4. The patient is not moderately obese. Page Ref: 663 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

11 ..

12) The nurse is preparing information for a community seminar on the hazards of obesity. Which disorder should the nurse include as being complications of obesity? Select all that apply. 1. Cardiovascular diseases 2. Obstructive sleep apnea 3. Diabetes mellitus type 2 4. Hypotension 5. Renal insufficiency Answer: 1, 2, 3 Explanation: 1. Obesity leads to atherosclerosis, which increases vascular resistance, predisposing the patient to cardiovascular diseases. 2. Respiratory airway collapse can occur during sleep in obese patients. 3. Obesity increases the risk of developing diabetes mellitus type 2 in adults. 4. Hypertension, not hypotension, is associated with obesity. 5. Patients who are obese are not necessarily at risk for developing renal insufficiency. Page Ref: 662 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

12 ..

13) A patient is suspected of having protein calorie malnutrition (PCM) with a body mass index of less than 18. Which laboratory test should the nurse expect to be prescribed for this patient? Select all that apply. 1. Serum albumin 2. Lymphocyte count 3. Serum electrolytes 4. Complete blood count (CBC) 5. Urinalysis Answer: 1, 2, 3 Explanation: 1. In PCM, serum albumin level is reduced. 2. In PCM, lymphocyte count is reduced. 3. In PCM, serum electrolytes are measured. Potassium levels are low in severe malnutrition. 4. CBC is an important measure, but it is not necessarily useful in determining protein calorie malnutrition. 5. Urinalysis is an important measure; it is not necessarily useful in determining protein calorie malnutrition. Page Ref: 676 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

13 ..

14) The nurse is reviewing data collected from an adolescent patient suspected of having anorexia nervosa. Which finding should the nurse identify as contributing to this diagnosis? Select all that apply. 1. Distorted body image 2. Loss of control over food intake 3. Purging 4. Binge eating 5. Normal or above average body weight Answer: 1, 2 Explanation: 1. Anorexia nervosa is an eating disorder characterized by distorted body image. 2. Anorexia nervosa is an eating disorder characterized by loss of control over food intake. 3. Purging is characteristic of bulimia nervosa. 4. Binge eating is characteristic of bulimia nervosa. 5. Normal or above average weight is characteristic of bulimia nervosa. Page Ref: 682 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

14 ..

15) A middle-aged female patient who weighs 130 lbs. (59.09 kg) and is 5 feet 2 inches tall (1.57 meters) wants assistance to develop a weight reduction plan. What is this patient's body mass index (BMI), which will help the nurse with nutritional planning? Record your answer rounding to the nearest whole number. Answer: 24 Explanation: Formula: [weight in kg] ÷ [height in meters]2 = [weight in kg] ÷ [height in meters × height in meters]. 59.09 divided by [1.57 ×1.57] = 59.09 divided by 2.4649 = 23.972574 [1 inch equals 0.0254 meters] Page Ref: 663 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders. 16) A patient weighs 200 lbs. (90.91 kg) and is 5 feet 6 inches tall (1.68 meters). What should the nurse calculate this patient's body mass index to be? Record your answer rounding to the nearest whole number. Answer: 32 Explanation: Formula: [weight in kg] ÷ [height in meters]2 = [weight in kg] ÷ [height in meters × height in meters]. 90.91 divided by [1.68 × 1.68] = 32.24 [1 inch equals 0.0254 meters] Page Ref: 663 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

15 ..

17) The nurse suspects that a patient has a vitamin C deficiency. What did the nurse assess to come to this conclusion? Select all that apply. 1. Delayed wound healing 2. Swollen bleeding gums 3. Depression 4. Night blindness 5. Muscle wasting Answer: 1, 2, 3 Explanation: 1. Vitamin C is critical for wound healing. 2. A manifestation of vitamin C deficiency is swollen, bleeding gums. 3. A manifestation of vitamin C deficiency is depression. 4. Night blindness is associated with vitamin A deficiency. 5. Muscle wasting is associated with calorie and thiamine deficiencies. Page Ref: 674 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

16 ..

18) A patient has been researching medications to help achieve a weight loss goal. What is the medication classification that the nurse should review with the patient that could help meet the patient's goal? 1. Lipase inhibitor 2. Antiepileptic 3. Anticholinergics 4. Adrenergics Answer: 1 Explanation: 1. A lipase inhibitor reduces fat absorption from the GI tract. 2. Antiepileptic medications are not prescribed for weight loss. 3. Anticholinergics are used in the treatment of Parkinson disease. 4. Adrenergics are generally used in the treatment of asthma. Page Ref: 664 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

17 ..

19) The goal of reducing or eliminating binge eating and purging behavior has been established for a patient with bulimia nervosa. What intervention should the nurse expect to be prescribed to help the patient achieve this goal? Select all that apply. 1. Nutritional counseling 2. Cognitive‒behavioral therapy 3. Antidepressants 4. Vitamin therapy 5. Hospitalization Answer: 1, 2, 3 Explanation: 1. Nutritional counseling is directed at establishing a regular meal pattern and encouraging an appropriate amount of regular exercise. 2. Cognitive‒behavioral therapy focuses on the patient's excessive concerns about weight, persistent dieting, and binge‒purge behaviors. 3. Many times patients binge eat and then purge because they are depressed. Using antidepressants may help the bulimic patient to prevent a relapse. 4. Vitamin therapy is usually associated with anorexia nervosa. 5. Hospitalization is usually associated with anorexia nervosa. Page Ref: 685 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

18 ..

20) The nurse is helping a 57-year-old patient design an exercise plan to achieve weight loss goals. What does the nurse calculate this patient's target heart rate to be? Record your answer rounding to the nearest whole number. Answer: 163 Explanation: Formula for calculating target heart rate is to subtract the patient's age from 220. For this patient, the target heart rate would be 220 − 57, or 163. Page Ref: 665 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders. 21) The nurse is preparing to administer total parenteral nutrition intravenously to a patient with malnutrition. What fat soluble vitamin should the nurse note is absent from the nutritional mixture? 1. Vitamin K 2. Vitamin A 3. Vitamin D 4. Vitamin E Answer: 1 Explanation: 1. Vitamin K is the only fat soluble vitamin that cannot be administered intravenously. 2. Vitamin A can be given IV. 3. Vitamin D can be given IV. 4. Vitamin E can be given IV. Page Ref: 677 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. 19 ..

MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders. 22) A patient has a body mass index (BMI) of 27. How should the nurse explain this finding to the patient? 1. Normal weight 2. Overweight 3. Obese 4. Metabolic syndrome Answer: 2 Explanation: 1. A body mass index of 18.5-24.9 is considered normal weight. 2. A body mass index of 25-25.9 is considered overweight. 3. A body mass index of 30-34.9 is considered obese. 4. Metabolic syndrome is a constellation of cardiovascular risk factors, including increased waist circumference, hypertension, elevated blood triglycerides and fasting blood glucose, and low HDL cholesterol. Metabolic syndrome is an identified risk factor for atherosclerosis and coronary heart disease (CHD). Page Ref: 663 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

20 ..

23) A patient has a waist-to-hip ratio of 0.5. Which health problem is this patient at risk for developing? 1. Gastrointestinal dysfunction 2. Hyperinsulinemia 3. Heart disease 4. Obesity Answer: 4 Explanation: 1. The low waist-to-hip ratio does not predispose this patient to develop gastrointestinal dysfunction. 2. The risk for hyperinsulinemia is lower in people with lower body obesity than in those with upper body obesity. 3. The risk for heart disease is lower in people with lower body obesity than in those with upper body obesity. 4. Lower body obesity may be more difficult to treat. Page Ref: 662 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

21 ..

24) A parent is overheard telling a child to behave in order to get an ice cream cone later. What should the nurse realize is occurring with the parent? 1. Rewarding behavior with food 2. Frustration with the child's behavior 3. Anxiety due to parenting 4. Hunger as a motivating factor Answer: 1 Explanation: 1. Sociocultural influences that contribute to obesity include overeating at family meals, rewarding behavior with food, religious and family gatherings that promote food intake, and sedentary lifestyles. 2. This comment does not indicate that the parent is frustrated with the child's behavior. 3. There is no evidence that the parent is anxious. 4. There is no evidence that the parent is hungry. Page Ref: 661 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Cultural Awareness/Cultural Influences on Health Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

22 ..

25) During a physical assessment, the nurse suspects that the patient might be experiencing metabolic syndrome. Which assessment finding provides evidence for this nurse's assumption? 1. Blood pressure 150/96 mmHg 2. Difficulty ambulating 3. Low waist-to-hip ratio 4. Heart rate 72 and regular Answer: 1 Explanation: 1. Individuals with metabolic syndrome are found to have three or more specific manifestations, one of which is hypertension. 2. Difficulty ambulating is not a manifestation of metabolic syndrome. 3. A low-waist-to hip ratio is not a manifestation of metabolic syndrome. 4. The heart rate is within normal limits and not a manifestation of metabolic syndrome. Page Ref: 662 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

23 ..

26) The nurse is reviewing the lipid panel of a patient with a body mass index (BMI) of 31. What should the nurse expect this patient's values to be? 1. Low high-density lipoprotein (HDL) 2. Elevated HDL 3. Normal thyroid hormone (TH) level 4. Reduced low-density lipoprotein (LDL) Answer: 1 Explanation: 1. LDL levels are elevated in obese patients. 2. HDL levels are reduced in obese patients. 3. There is no relationship between BMI and TH. 4. LDL levels are elevated in obese patients. Page Ref: 662 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

24 ..

27) A patient with a BMI of 29 is upset because of not losing any weight despite cutting out all sweet snacks. How should the nurse respond to this patient? 1. "Let's calculate how many calories you are not eating each day." 2. "I recommend that you go see a dietician." 3. "I'll make a note in your file that you are no longer eating sweet snacks." 4. "You didn't gain the weight overnight." Answer: 1 Explanation: 1. A pound of body fat is equivalent to 3500 kilocalorie (kcal). To lose one pound, therefore, a person must reduce daily caloric intake by 250 kcal for 14 days or increase activity enough to burn the equivalent kcal. 2. There is no need for the nurse to refer the patient to a dietician. Dietary teaching about weight reduction is within the nurse's scope of practice. 3. Documenting the patient's comments is not the priority. 4. Discussing the time it took for the patient to gain the weight will not promote a therapeutic environment. Page Ref: 664 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

25 ..

28) A patient who lives alone has a BMI of 34. What strategy should the nurse suggest to help this patient reduce overeating? 1. Prepare a meal and eat it in the dining room. 2. Eat out more often to control portion size. 3. Read a book while eating as a distraction from the food. 4. Cook once a week and store the leftovers to reduce the need to cook again. Answer: 1 Explanation: 1. One strategy to control the psychological response to food is to use attractive dinnerware, and prepare a formal setting for eating which would occur in a dining room. 2. Eating out in restaurants should be reduced. 3. Reading or watching television while eating should not be encouraged. 4. Cooking so much that there are leftovers is also not a good strategy. Page Ref: 666 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

26 ..

29) An overweight patient reports not being able to stop eating bagels that are provided every Monday morning at work. What should the nurse realize this patient is describing? 1. Appetite stimulation by external cues 2. Extreme hunger from calorie restriction 3. Carbohydrate addiction in its early stage 4. Metabolic syndrome development Answer: 1 Explanation: 1. Most overweight people are stimulated to eat by external cues, such as the proximity to food and the time of day. 2. In contrast, hunger and satiety are the cues that regulate eating in adults of normal weight. The patient's reports involve eating with no mention of hunger. 3. There is no evidence to support the presence of any addiction. 4. There is no evidence to support the presence of metabolic disorder. Page Ref: 666 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

27 ..

30) A patient regained 15 lbs. that had been lost the previous year. What should the nurse suggest to this patient? 1. Return to the diet, exercise, and behavior change techniques that worked before. 2. Switch to a new diet in which the weight could be lost again in two weeks. 3. Consider the possibility that the patient's body needs to have the extra 15 lbs. 4. Understand that the increased weight does not make the patient obese. Answer: 1 Explanation: 1. The potential risks associated with regaining weight make maintenance a critical issue. Patients are encouraged to continue exercise, self-monitoring, and treatment support. 2. Long-term weight loss and maintenance mean a lifelong commitment to significant lifestyle changes, including food and eating habits, activity and exercise routines, and behavior modification. 3. There is no evidence that the patient's body needs to have the extra 15 lbs. 4. There is no evidence that the patient is not obese. Page Ref: 668 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

28 ..

31) An overweight patient tries to adhere to a diet and exercise plan but family members say the patient does not need to lose any weight. What type of problem is this patient experiencing? 1. Lack of family and social support to adhere to the plan 2. Eating more than is required for bodily functions 3. Difficulty with exercise and activity 4. Generalized feelings of self-reproach Answer: 1 Explanation: 1. Family and social support is critical to successful adherence to the therapeutic regimen. Without family support, the patient will have difficulty adhering to the weight loss plan. 2. There is no evidence that the patient is eating more than is required for bodily functions. 3. There is no evidence that the patient is having difficulty with exercise and activity. 4. There is no evidence that the patient has generalized feelings of self-reproach. Page Ref: 671 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

29 ..

32) An older patient who uses a walker reports feeling alone since all family members are gone. Which health problem is this patient at risk for developing? 1. Malnutrition 2. Obesity 3. Psychosis 4. Immobility Answer: 1 Explanation: 1. Older patients are at increased risk for malnutrition. Functional limitations can impair the ability to shop and cook. Psychosocial issues also contribute to the problem. Loss of appetite is a problem that is commonly seen with depression. Social isolation and loneliness contribute to the problem. 2. There is no evidence that this patient is at risk for developing obesity. 3. There is no evidence that this patient is at risk for developing psychosis. 4. There is no evidence that this patient is at risk for developing immobility. Page Ref: 673 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

30 ..

33) A patient is being evaluated for malnutrition. Which laboratory test result should the nurse recognize will support that finding? Select all that apply. 1. Low serum potassium 2. Low white blood cell count 3. Elevated serum albumin 4. Elevated red blood cell count 5. Low serum sodium Answer: 1, 2 Explanation: 1. Potassium levels are low in severe malnutrition. 2. The total lymphocyte count (white blood cell count) is reduced in malnutrition. 3. Elevated serum albumin level indicates adequate nutrition. 4. There are no specific findings regarding red blood cell count with malnutrition. 5. There is no specific finding regarding serum sodium level with malnutrition. Page Ref: 676 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

31 ..

34) A patient with malnutrition is experiencing ongoing diarrhea after every meal. Which health problem could this patient be experiencing? 1. Malabsorption 2. A food allergy 3. Carbohydrate intolerance 4. Pending cardiovascular overload Answer: 1 Explanation: 1. Refeeding can precipitate malabsorption and diarrhea. 2. The diarrhea occurs after each meal, not only with foods that may cause an allergy. 3. The diarrhea occurs after each meal, not only with foods that are carbohydrates. 4. Cardiovascular overload does not precipitate the development of diarrhea after eating. Page Ref: 676 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

32 ..

35) A patient is prescribed a hypertonic solution with vitamins and minerals to be administered through a peripheral intravenous access line. Which type of treatment should the nurse prepare teaching for this patient? 1. Intravenous fluid support 2. Total parenteral nutrition 3. Enteral nutrition 4. Short-term total parenteral nutrition Answer: 4 Explanation: 1. A hypertonic solution with vitamins and minerals is not the usual intravenous fluid mixture for fluid support. 2. Total parenteral nutrition (TPN) would be administered through a central vein. 3. Enteral nutrition is delivered directly into the gastrointestinal system. 4. A peripherally inserted central catheter (PICC) line may be used for short-term TPN. Page Ref: 678 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

33 ..

36) The parent of a preadolescent patient reports the child seeing an overweight adolescent and has since refused to eat. What behavior is this patient most likely demonstrating? 1. An irrational fear of gaining weight 2. Defiance directed at the parent 3. Normal preadolescent behavior 4. An internal power struggle Answer: 1 Explanation: 1. Anorexia nervosa typically begins during adolescence. Patients with anorexia nervosa have a distorted body image and irrational fear of gaining weight. 2. Defiant behaviors involve rebellion. The child is not demonstrating that type of behavior. 3. It is not normal for a preadolescent child to discontinue eating. 4. The child is not demonstrating behaviors consistent with an internal power struggle. Page Ref: 682 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

34 ..

37) A young adult patient reports eating anything that is desired and has a laxative "for dessert." Which behavior is this patient demonstrating? 1. Bulimia 2. Anorexia 3. Effective weight control 4. Distorted body image Answer: 1 Explanation: 1. In bulimia and after binge eating, the patient may induce vomiting or take excessive quantities of laxatives or diuretics. 2. Anorexic behaviors involve avoidance of eating. 3. Laxative use is not a healthful means to control body weight. 4. There is no discussion of the patient's perceived body image. Page Ref: 683 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with nutritional disorders.

35 ..

38) The parent of an adolescent patient being evaluated for bulimia asks what diagnostic tests can be done. What is the nurse's best response? 1. "There is no specific test that can determine bulimia." 2. "You should ask the doctor about this." 3. "Your child will need a psychiatric evaluation to determine the diagnosis." 4. "Bulimia is rarely diagnosed correctly." Answer: 1 Explanation: 1. There is no specific diagnostic test for bulimia. 2. It is not necessary to refer the parent to the physician. 3. A psychiatric evaluation may be indicated after a diagnosis is made. The information being sought by the patient's parent can be provided by the nurse. 4. Bulimia can be diagnosed by a competent physician when adequate information is present. Page Ref: 685 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 22.3 Describe the pathophysiology and manifestations of eating disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

36 ..

39) A patient is admitted for treatment of malnutrition. What assessment finding does the nurse identify that indicates the patient is experiencing a vitamin C deficiency? 1. Bleeding gums 2. Smooth tongue 3. Muscle cramps 4. Ataxia Answer: 1 Explanation: 1. Physical assessment information to suggest a vitamin C deficiency includes swollen bleeding gums. 2. A smooth tongue is consistent with an iron deficiency. 3. Manifestations of a thiamine deficiency includes muscle cramps. 4. Manifestations of a thiamine deficiency includes ataxia. Page Ref: 674 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

37 ..

40) At the conclusion of a physical assessment the nurse determines that a patient is experiencing health-related problems of obesity. What information from the patient's health history does the nurse use to make this decision? Select all that apply. 1. Osteoarthritis 2. Varicose veins 3. Low back pain 4. Allergy to sulfa 5. Lactose intolerance Answer: 1, 2, 3 Explanation: 1. Osteoarthritis is an obesity-related problem of the musculoskeletal system. 2. Varicose veins are an obesity-related problem of the cardiovascular system. 3. Low back pain is an obesity-related problem of the musculoskeletal system. 4. A drug allergy is not an obesity-related problem. 5. Lactose intolerance is not an obesity-related problem. Page Ref: 660 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

38 ..

41) The nurse is reviewing prescribed medications for a patient with obesity. Which medication would the nurse recognize as contraindicated for patients taking lorcaserin (Belviq)? Select all that apply. 1. Aspirin (ASA) 2. St. John's wort 3. Ibuprofen (Motrin) 4. Furosemide (Lasix) 5. Bupropion (Wellbutrin) Answer: 2, 5 Explanation: 1. There is no reason to question providing lorcaserin (Belviq) with aspirin (ASA). 2. Lorcaserin (Belviq) activates the serotonin 5-HT 2c receptor in the brain, causing an individual to feel full after eating smaller amounts and therefore eating less. Coadministration with other drugs that increase serotonin levels can lead to serotonin syndrome or even neuroleptic malignant syndrome. This medication should be avoided or used with extreme caution by patients taking St. John's wort. 3. There is no reason to question providing lorcaserin (Belviq) with ibuprofen (Motrin). 4. There is no reason to question providing lorcaserin (Belviq) with furosemide (Lasix). 5. Lorcaserin (Belviq) activates the serotonin 5-HT 2c receptor in the brain, causing an individual to feel full after eating smaller amounts and therefore eating less. Coadministration with other drugs that increase serotonin levels can lead to serotonin syndrome or even neuroleptic malignant syndrome. This medication should be avoided or used with extreme caution for patients taking bupropion (Wellbutrin). Page Ref: 663 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 2. Consider intraprofessional care for patients with nutritional disorders.

39 ..

42) A patient is prescribed a 1750 kilocalorie eating plan where 15% of the daily intake is to be protein. How many kilocalories of protein should the nurse instruct the patient to ingest each day? ________ kcal Record your answer rounding up to the nearest whole number. Answer: 263 Explanation: To determine the percentage of permitted protein intake, the nurse should multiply the total daily kilocalorie intake by 15% or 1750 × 15% = 262.5 or 263 kcal. Page Ref: 666 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

40 ..

43) The nurse is providing discharge teaching to a patient recovering from bariatric surgery. Which patient statement indicates that teaching about dumping syndrome has been effective? Select all that apply. 1. "I should eat three large meals each day." 2. "I should have tea and toast for breakfast." 3. "I should not drink fluids while eating a meal." 4. "I should lie down for 30 minutes after eating a meal." 5. "I should avoid eating foods high in simple carbohydrates." Answer: 3, 5 Explanation: 1. Patients recovering from bariatric surgery should eat small meals. 2. Tea and toast will not prevent dumping syndrome. 3. Patients recovering from bariatric surgery should be instructed not to eat liquids and solids together. 4. It is not necessary for the patient recovering from bariatric surgery to lie down after eating. This will not prevent dumping syndrome. 5. Patients recovering from bariatric surgery should be instructed to avoid foods high in simple carbohydrates. Page Ref: 667-668 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 22.1 Describe the pathophysiology, manifestations, and complications of obesity, and outline the interprofessional care and nursing care of patients with obesity. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with nutritional disorders.

41 ..

44) A patient with protein-calorie malnutrition has been ingesting a hyperosmolar nutritional supplement three times a day for a week. Which assessment finding indicates that this patient is experiencing dehydration? Select all that apply. 1. Weight loss 2. Dry mucous membranes 3. High urine specific gravity 4. New skin blister on sacrum 5. Change in level of consciousness Answer: 1, 2, 3, 5 Explanation: 1. Weight loss indicates a drop in body fluid or dehydration. Weighing daily helps monitor fluid balance. 2. Dry mucous membranes may indicate dehydration. 3. Increased urine specific gravity may indicate dehydration. 4. A new skin blister on the sacrum indicates a protein deficiency. 5. A change in level of consciousness may indicate dehydration. Page Ref: 681 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 22.2 Describe the pathophysiology and manifestations of malnutrition, and outline the interprofessional care and nursing care of patients with malnutrition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with nutritional disorders.

42 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 23 Nursing Care of Patients with Upper Gastrointestinal Disorders 1) A patient has been diagnosed with type 1 herpes simplex lesions on the mouth and face. Which statement indicates that the patient understands teaching provided by the nurse? 1. "I will have this condition for life." 2. "This was caused by a bacterial infection." 3. "This is a type of fungal infection." 4. "An antibiotic will help heal these sores in about 3 days." Answer: 1 Explanation: 1. Herpes simplex is a viral infection. The virus remains latent and can recur during stressful events, fever, trauma, sunlight exposure, and treatment with immunosuppressive drugs. 2. The condition is not caused by a bacterial infection. 3. Herpes simplex is not a fungal infection. 4. The condition is not managed with antibiotics. Page Ref: 698 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper gastrointestinal disorders.

1 ..

2) Acyclovir (Zovirax) ointment has been prescribed for a patient with oral herpes lesions. What should the nurse include when providing information to the patient regarding this medication? Select all that apply. 1. Take the medication with food. 2. It can reduce the length of the herpes outbreak. 3. It is an antibiotic medication. 4. Repeated usage of the drug usually leads to permanent remission. 5. It is most effective when administered intravenously. Answer: 1, 2 Explanation: 1. This medication should be administered with food. 2. Acyclovir is used to reduce the severity and length of an outbreak of herpes simplex. 3. Acyclovir is an antiviral agent. 4. Herpes simplex is a viral condition that is not curable, and outbreaks are likely to occur when the patient is physically and/or emotionally stressed. 5. For patients with intact immune systems, oral acyclovir (Zovirax) is generally used. Page Ref: 699 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

2 ..

3) A patient is diagnosed with an oral fungal infection. What should the nurse anticipate being prescribed to manage this health problem initially? 1. Nystatin 2. Fluconazole 3. Ampicillin 4. Anbesol Answer: 1 Explanation: 1. Initial management of an oral fungal infection typically includes nystatin. The medication is administered as a "swish and swallow." 2. If the initial medication does not resolve the infection, an oral medication such as fluconazole may be prescribed. 3. Ampicillin is an antibiotic used to manage bacterial infections. 4. Anbesol is used to manage oral discomfort, which can accompany a mouth infection. Page Ref: 698 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

3 ..

4) The nurse is developing the postoperative plan of care for a patient recovering from surgery for oral cancer. Which potential problem should the nurse identify as the priority for this patient? 1. Airway maintenance 2. Communication 3. Body image change 4. Insufficient oral intake Answer: 1 Explanation: 1. The location and extent of an oral cancer and its excision may compromise the airway. This would be the priority for the patient. 2. Although communication is important, it is not a priority problem for this patient. 3. Although body image is important, it is not a priority problem for this patient. 4. Oral intake would be the next priority problem. Page Ref: 702 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

4 ..

5) The nurse is caring for a patient with gastroesophageal reflux disease (GERD). What should the nurse include when teaching the patient about this health problem? Select all that apply. 1. Limit last food intake to 3 hours before bedtime. 2. Eat the largest meal of the day at midday. 3. Sleep in a bed with the head elevated 6 to 8 inches. 4. Follow a daily exercise routine. 5. Drink coffee with meals. Answer: 1, 3 Explanation: 1. The patient should avoid eating anything within 3 hours of bedtime. 2. The patient should be instructed to eat small, frequent meals. 3. The head of the bed should be elevated on 6- to 8-inch blocks. 4. An exercise routine is not identified in the treatment of GERD. 5. Coffee increases gastric acidity and interferes with gastric emptying, increasing the incidence of gastroesophageal reflux. Page Ref: 709 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

5 ..

6) A patient receiving an antacid is experiencing muscle cramps. What should the nurse do to assist this patient? 1. Notify the healthcare provider. 2. Review the patient's diet history. 3. Review the patient's elimination patterns. 4. Provide reassurance to the patient. Answer: 1 Explanation: 1. Antacids may cause electrolyte imbalances, particularly involving sodium, calcium, and magnesium. Notify the healthcare provider so serum electrolytes can be drawn and reviewed. 2. There is no indication that the patient's dietary history is an issue. 3. There is no indication that the patient's elimination patterns are an issue. 4. Providing reassurance to the patient at this time would be premature, as the complaints are being reported and not adequately reviewed. Page Ref: 707 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

6 ..

7) A patient who has been experiencing nausea expresses an interest in aromatherapy to manage the condition. What response by the nurse would be most therapeutic? 1. "Ginger has been used with some success to manage nausea." 2. "Aromatherapy has shown very limited effectiveness with nausea." 3. "Aromatherapy helps to exert conscious control over physiologic processes." 4. "Why are you considering this method?" Answer: 1 Explanation: 1. Ginger is an aromatic root. It has demonstrated success in managing nausea in some populations. 2. Telling the patient the substance has limited effectiveness is discouraging and not entirely true. 3. Biofeedback is the nonpharmacologic method that allows conscious control to be exerted over a physiologic process. 4. Questioning the patient does not meet the patient's request for information. Page Ref: 695 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

7 ..

8) The nurse is assessing a patient diagnosed with gastrointestinal bleeding. Which finding should alert the nurse that the patient's condition is deteriorating? 1. The patient reports feeling very tired. 2. Urinary output has increased over the previous hour to 50 mL. 3. The patient's skin is warm and dry. 4. Capillary refill time has increased. Answer: 1 Explanation: 1. Alterations in level of consciousness can signal an increase in blood loss. This warrants further investigation. 2. Urinary output should remain greater than 30 mL per hour. 3. Skin characteristics such as warmth and dryness are normal. 4. Capillary refill time decreases, not increases, with increased blood loss. Page Ref: 714 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

8 ..

9) Four weeks post gastric resection surgery, a patient is experiencing cramping, nausea, and diarrhea within 10 minutes after eating. Suspecting that the patient may have dumping syndrome, what should the nurse suggest? Select all that apply. 1. Increase protein in the diet. 2. Lie down for 30 minutes immediately after eating. 3. Eat frequent, small meals. 4. Reduce the amount of carbohydrates eaten daily. 5. Drink a glass of water prior to each meal. Answer: 1, 2, 3, 4 Explanation: 1. Increasing the amount of protein and fat in the diet will help slow the transit time through the digestive tract. 2. The patient should be instructed to lie down for 30 to 60 minutes after eating to slow transit time through the digestive tract. 3. The symptoms can be managed by eating small, more frequent meals. 4. Carbohydrate consumption should be reduced to help slow the transit time through the digestive tract. 5. Drinking before eating might intensify the problem. Page Ref: 728 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

9 ..

10) A patient diagnosed with peptic ulcer disease (PUD) asks if surgery will be necessary. How should the nurse respond? 1. "Taking the appropriate medications makes surgery rarely necessary." 2. "Surgery is required in about 50% of cases." 3. "Surgery has a higher success rate than medication therapy alone." 4. "If you take your medications and follow the prescribed diet, you will likely not need surgery." Answer: 1 Explanation: 1. With the identification of H. pylori infection as the major cause of peptic ulcers and the development of medications to eradicate this organism, surgery is rarely necessary. 2. Surgery may be required to treat a complication of PUD, such as hemorrhage, perforation, or gastric outlet obstruction. 3. The success rate of pharmacologic intervention to eradicate H. pylori is 75% to 90%. 4. There are no specific dietary modifications for PUD. Page Ref: 720 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

10 ..

11) The spouse of a patient recently diagnosed with terminal esophageal cancer is angry because the patient did not seek help sooner. Which response by the nurse would be the most appropriate at this time? 1. "Unfortunately, the early symptoms are often vague and often not recognized as something serious." 2. "Your spouse was probably afraid of getting bad news." 3. "You will never know." 4. "It is not important to know that right now." Answer: 1 Explanation: 1. The manifestations of esophageal cancer are often vague. Difficulty swallowing does not manifest until approximately 60% of the esophagus is affected. By this time, the condition is often terminal. 2. It is inappropriate for the nurse to make assumptions about the motivations and feelings of an individual with cancer. 3. It is presumptuous for the nurse to suggest the patient's spouse will "never know." 4. It is inappropriate for the nurse to decide what is important for the patient's spouse to know at this time. Page Ref: 710 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper gastrointestinal disorders.

11 ..

12) A patient complains of heartburn, reflux, and belching. Which diagnostic test should the nurse anticipate being prescribed for this patient? 1. Barium swallow 2. Colonoscopy 3. Barium enema 4. Chest x-ray Answer: 1 Explanation: 1. A hiatal hernia is consistent with the symptoms being reported. A barium swallow or an upper endoscopy may be performed to diagnose hiatal hernia. 2. A colonoscopy is used to diagnose problems with the lower gastrointestinal tract. 3. A barium enema is used to diagnose problems with the lower gastrointestinal tract. 4. A chest x-ray would not help diagnose a problem with the gastrointestinal tract. Page Ref: 709 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

12 ..

13) A patient recovering from gastric surgery has red fluid in the nasogastric tube. Vital signs are temperature 98°F; heart rate 104 beats per minute; respirations 23 breaths per minute; blood pressure 105/69 mmHg. Which action by the nurse is indicated? 1. Document the findings and notify the healthcare provider. 2. Document the findings and reassess the patient in 4 hours. 3. Review the patient's most recent laboratory results. 4. Document the findings and review the nasogastric suction settings. Answer: 1 Explanation: 1. The patient's assessment is consistent with an early hemorrhage. The situation warrants contacting the healthcare provider. 2. Reassessment of the patient in 4 hours would allow too much time to pass before reevaluation and may result in serious complications. 3. The laboratory values might yield useful information but would be secondary to another action. 4. The nasogastric suction settings can be reviewed, but another action must be performed first. Page Ref: 722 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

13 ..

14) The nurse is caring for a patient who has been vomiting for 3 days. On which potential acidbase and electrolyte complications should the nurse focus when caring for this patient? Select all that apply. 1. Hypokalemia 2. Metabolic alkalosis 3. Metabolic acidosis 4. Hypocalcemia 5. Hyponatremia Answer: 1, 2 Explanation: 1. Decreased potassium results from potassium losses through the emesis. 2. Metabolic alkalosis results from loss of hydrochloric acid from the stomach during vomiting. 3. Acidosis can occur when there is too much hydrochloric acid. 4. While decreased calcium can be problematic, it is not associated with vomiting. 5. While decreased sodium can be problematic, it is not associated with vomiting. Page Ref: 693 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

14 ..

15) The nurse is identifying interventions to assist a patient experiencing nausea and vomiting. Which complementary and alternative approach should the nurse consider to help this patient? Select all that apply. 1. Adding ginger to the diet 2. Biofeedback 3. Music therapy 4. Acupuncture 5. Taking St. John's wort Answer: 1, 2, 3, 4 Explanation: 1. Ginger has been used to relieve nausea and vomiting. 2. Biofeedback has been used to relieve nausea and vomiting. 3. Music therapy has been used to relieve nausea and vomiting. 4. Acupuncture may relieve nausea and vomiting. 5. St. John's wort is used in the treatment of depression. Page Ref: 695 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

15 ..

16) The nurse is caring for a patient who is experiencing a new onset of gastrointestinal bleeding. In which order should the nurse assess this patient? Place in order the steps of the process. Choice 1. Identify possible contributing factors, including medications. Choice 2. Obtain vital signs, including orthostatic changes. Choice 3. Place the acutely ill patient on a cardiac monitor and obtain a rhythm strip. Choice 4. Evaluate mental status. Choice 5. Assess peripheral pulse strength, color, temperature, and cap refill of extremities. Choice 6. Obtain oxygen saturation level. Answer: 1, 2, 3, 6, 5, 4 Explanation: It is imperative to first assess for possible contributing factors. Obtaining vital signs and orthostatic vital signs can assess for early signs of hypovolemia. Placing the patient on a monitor and obtaining a rhythm strip help determine if arrhythmias are present. The oxygen saturation level helps determine if the body is being adequately oxygenated. Assessing peripheral pulse strength, color, temperature, and cap refill of extremities is part of the headto-toe physical assessment. Evaluation of mental status, including level of consciousness and orientation, may provide clues to the extent of the hemorrhage and its effect on the oxygencarrying capacity of remaining red blood cells. Page Ref: 714 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

16 ..

17) The nurse expects that a dopamine antagonist will be prescribed for a patient who is experiencing nausea and vomiting. Which medication should the nurse anticipate being prescribed for this patient? Select all that apply. 1. Prochlorperazine (Compazine) 2. Thiethylperazine (Torecan) 3. Metoclopramide (Reglan) 4. Ondansetron (Zofran) 5. Hydroxyzine (Vistaril) Answer: 1, 2, 3 Explanation: 1. Prochlorperazine (Compazine) is a dopamine antagonist. 2. Thiethylperazine (Torecan) is a dopamine antagonist. 3. Metoclopramide (Reglan) is a dopamine antagonist. 4. Ondansetron (Zofran) is a serotonin receptor antagonist. 5. Hydroxyzine (Vistaril) is an antihistamine. Page Ref: 694 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

17 ..

18) A patient is being prepared for chemotherapy, and the doctor has ordered Zofran 0.15 mg/kg IV to be given 30 minutes prior to starting the chemotherapy. The patient weighs 80 kg. How many milligrams of Zofran will the patient receive? Record your answer rounding to the nearest whole number. Answer: 12 Explanation: 0.15 mg/kg × 80 kg = 12 mg Page Ref: 694 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

18 ..

19) The nurse is teaching a patient with stomatitis about mouth care. What should the nurse include in this teaching? Select all that apply. 1. Avoid tobacco and alcohol. 2. Use a saline or sodium bicarbonate rinse after every meal. 3. Consume 8 oz of yogurt or buttermilk daily. 4. Avoid cold beverages. 5. Use lemon-glycerin swabs between meals. Answer: 1, 2, 3 Explanation: 1. The patient should be instructed to avoid the use of tobacco and alcohol as they damage the oral mucosa and increase the risk for oral mucositis. 2. Saline or sodium bicarbonate rinses are buffering agents that are gentler on the oral mucosa. 3. Patients taking an extended course of antibiotic therapy or who have impaired immune function should consume 8 oz of yogurt containing live bacterial cultures or 8 oz of buttermilk daily. 4. Cold drinks generally are more soothing than hot drinks, which should be avoided. 5. Lemon-glycerin swabs are drying to the oral mucosa and should be avoided. Page Ref: 700 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

19 ..

20) A patient is being evaluated for gastroesophageal reflux disease (GERD). Which diagnostic test should the nurse expect to be prescribed for this patient? Select all that apply. 1. Barium swallow 2. Upper endoscopy 3. CT scan 4. Complete blood count 5. Colonoscopy Answer: 1, 2 Explanation: 1. Diagnostic tests for gastroesophageal reflux disease include a barium swallow, which evaluates the esophagus, stomach, and upper intestine. 2. Diagnostic tests for gastroesophageal reflux disease include upper endoscopy, which allows direct visualization of the esophagus. 3. A CT scan is not a diagnostic test for gastroesophageal reflux disease. 4. A complete blood count is not a diagnostic test for gastroesophageal reflux disease. 5. A colonoscopy is not a diagnostic test for gastroesophageal reflux disease. Page Ref: 706 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

20 ..

21) The nurse is teaching a patient about the major risk factors for peptic ulcer disease (PUD). Which risk factors should the nurse discuss? Select all that apply. 1. Chronic H. pylori infection 2. Use of aspirin and NSAIDs 3. Use of alcohol 4. Dietary intake 5. Stress Answer: 1, 2 Explanation: 1. Chronic H. pylori infection is a major risk factor for PUD. 2. The use of aspirin and NSAIDs is a major risk factor for PUD. 3. Alcohol use is not a major risk factor for PUD. 4. Dietary intake is not a major risk factor for PUD. 5. The role of stress is uncertain in PUD. Page Ref: 716 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper gastrointestinal disorders.

21 ..

22) The healthcare provider has prescribed metoclopramide (Reglan) 2 mg/kg IVP to be given 30 minutes before the start of chemotherapy. The patient weighs 54 kg. The Reglan is dispensed in a 10 mg/10 mL vial. How many milliliters of the medication should the nurse administer? Record your answer rounding to the nearest whole number. Answer: 11 Explanation: 54 ×2 divided by 10 mg/10 mL = 10.8 ccs Page Ref: 708 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper gastrointestinal disorders.

22 ..

23) The nurse learns that an older patient with ill-fitting dentures has been using an over-thecounter (OTC) preparation for a gum sore over the last month. What should the nurse instruct this patient to do? 1. Make an appointment to see the physician. 2. Continue to use the preparation. 3. Change the preparation. 4. Stop wearing the dentures. Answer: 1 Explanation: 1. The nurse should encourage patients with ill-fitting dentures or other dental prostheses (such as partial plates) to see a qualified dentist or denturist. 2. Because the current OTC remedy is not effective, the patient should stop using it and see the physician before using a different OTC preparation. 3. Because the current OTC remedy is not effective, the patient should stop using it and see the physician before using a different OTC preparation. 4. Not wearing the dentures can lead to nutritional problems and social isolation. Page Ref: 700 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

23 ..

24) A patient with a long history of using chewing tobacco says, "I've been chewing for years. I'm not going to get cancer." How should the nurse respond? 1. "The use of smokeless tobacco has been linked to oral cancer." 2. "You are probably one of the lucky ones." 3. "I guess you're right." 4. "It's not my body." Answer: 1 Explanation: 1. Using chewing tobacco is a primary risk factor for oral cancer. 2. This is a nontherapeutic response. 3. Agreeing with the patient is not therapeutic. 4. This is a nontherapeutic response. Page Ref: 701 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper gastrointestinal disorders.

24 ..

25) A patient who needs a radical neck dissection for oral cancer continues to delay the surgery. Which issue may be influencing the patient's decision-making process? 1. Potential for change in body image 2. Future problem with communication 3. Fear about not being able to eat 4. Fear about not being able to breathe Answer: 1 Explanation: 1. Radical surgery of the head or neck seriously affects body image. Patients may defer lifesaving surgery to postpone disfiguring interventions or therapies. 2. There is not enough information to determine if the patient is postponing surgery because of a future problem with communication. 3. There is not enough information to determine if the patient is postponing surgery because of a fear of not being able to eat. 4. There is not enough information to determine if the patient is postponing surgery because of a fear of not being able to breathe. Page Ref: 703 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

25 ..

26) The nurse is preparing to instruct a patient newly diagnosed with gastroesophageal reflux disease (GERD) about dietary considerations. What should the nurse include in these instructions? Select all that apply. 1. "Avoid peppermint." 2. "Meals should be small and more frequent." 3. "Have a bedtime snack." 4. "Be sure to eat at least one citrus fruit per day." 5. "Alcohol should be limited to two drinks per day." Answer: 1, 2 Explanation: 1. Peppermint relaxes the lower esophageal sphincter or delays gastric emptying and should be avoided. 2. The patient should be advised to eat smaller meals. 3. The patient should be advised to refrain from eating for 3 hours before bedtime. 4. Acidic foods such as citrus fruits should be eliminated from the diet. 5. Alcohol relaxes the lower esophageal sphincter and should be avoided. Page Ref: 709 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

26 ..

27) The nurse is preparing the morning medications for a patient with gastroesophageal reflux disease (GERD). Which nursing intervention would be appropriate for this patient's medications? 1. Hold the antacids for at least 2 hours after oral medications are taken. 2. Provide all prescribed medications at 1000. 3. Provide the antacids first, then follow with the oral medications. 4. Provide the antacids only at the hour of sleep. Answer: 1 Explanation: 1. Antacids interfere with the absorption of many drugs given orally, and administration times should be separated by at least 2 hours. 2. Medication administration should not be delayed. 3. Antacids should be provided after other medications. 4. Antacids may not be appropriate at the hour of sleep. Page Ref: 707 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

27 ..

28) A patient with gastrointestinal dysfunction says, "I was having chest pain so bad last week I thought I was having a heart attack!" What should the nurse suspect the patient was experiencing? 1. Hiatal hernia 2. Diverticulitis 3. Constipation 4. Bowel obstruction Answer: 1 Explanation: 1. Manifestations of hiatal hernia include substernal chest pain. 2. Diverticulitis is not associated with substernal chest pain. 3. Constipation is not associated with substernal chest pain. 4. Bowel obstruction is not associated with substernal chest pain. Page Ref: 709 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

28 ..

29) A patient who is experiencing difficulty swallowing is diagnosed with esophageal cancer after having a barium swallow. Which finding is consistent with this patient's health problem? 1. Narrow esophageal lumen 2. Tumor 3. Metastasis 4. Blood Answer: 1 Explanation: 1. With a barium swallow, esophageal cancer is seen as a narrowing of the lumen or an irregular mucosal pattern. 2. Other testing would be needed to detect an actual tumor. 3. Other testing would be needed to detect metastasis. 4. Other testing would be needed to detect bleeding. Page Ref: 711 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

29 ..

30) A patient with nausea refuses to take a medication because it makes the nausea worse. What can the nurse suggest to the patient? 1. Eat a dry cracker to help with the nausea. 2. Stop taking the medication. 3. Nothing. 4. Take the medication with a heavy meal. Answer: 1 Explanation: 1. In most cases, nausea and vomiting are self-limiting and require no treatment. Dry food such as soda crackers may reduce nausea and promote comfort. 2. Discontinuing the medication will stop the desired action for which the medication has been prescribed. 3. Taking no action does not meet the needs of the patient. 4. Taking medication with a heavy meal may increase the nausea. Page Ref: 693 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

30 ..

31) A patient with chronic gastritis stops taking prescribed medication and uses ginger tea instead. What should the nurse realize is occurring with this patient? 1. Using a complementary therapy for the symptoms. 2. In denial of the disease 3. Cannot afford the medication 4. Needs to see the healthcare provider immediately Answer: 1 Explanation: 1. Complementary therapies such as herbal remedies or aromatherapy may be appropriate to recommend for patients with gastritis. Recommendations may include ginger in the form of powder, capsules, or tea taken before or after meals. 2. This action does not indicate denial. 3. This action does not indicate inability to pay for the medication. 4. The healthcare provider should be made aware of the fact that the patient is not taking the prescribed medication; however, it is not an immediate concern. Page Ref: 726 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

31 ..

32) A patient reports having stomach pains during the night that disappear after eating. Which health problem should the nurse suspect this patient is experiencing? 1. Peptic ulcer disease 2. Gastroesophageal reflux disease (GERD) 3. Acute gastritis 4. Chronic gastritis Answer: 1 Explanation: 1. Pain is the classic symptom of peptic ulcer disease. The pain is typically described as gnawing, burning, aching, or hungerlike; it is experienced in the epigastric region and sometimes radiates to the back. The pain occurs when the stomach is empty (2 to 3 hours after meals and in the middle of the night) and is relieved by eating in a classic "pain-foodrelief" pattern. 2. This classic pattern is not typical of gastroesophageal reflux disease (GERD). 3. This classic pattern is not typical of acute gastritis. 4. This classic pattern is not typical of chronic gastritis. Page Ref: 719 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper gastrointestinal disorders.

32 ..

33) The nurse learns that a patient who is being treated for peptic ulcer disease is "still having problems." What should the nurse instruct this patient to do? 1. Try smoking cessation techniques. 2. Eat a bland diet. 3. Avoid eating breakfast. 4. Have the largest meal of the day at lunchtime. Answer: 1 Explanation: 1. Smoking should be discouraged, because it slows the rate of healing and increases the frequency of relapses. 2. Diet therapy for peptic ulcer disease includes having the patient eat several small meals per day and avoid foods that produce symptoms, rather than prescribing a particular diet such as a bland diet. 3. Diet therapy for peptic ulcer disease includes having the patient eat several small meals per day and avoid foods that produce symptoms. There is no need to avoid eating breakfast. 4. Diet therapy for peptic ulcer disease includes having the patient eat several small meals per day and avoid foods that produce symptoms, rather than having a large meal at lunchtime. Page Ref: 727 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

33 ..

34) A patient with peptic ulcer disease (PUD) reports feeling better since not eating. Which health problem is this patient at risk for developing? 1. Insufficient nutritional intake 2. Insomnia 3. Ongoing pain 4. Overhydration Answer: 1 Explanation: 1. In an attempt to avoid discomfort, the patient with PUD may gradually reduce food intake and sometimes jeopardize nutritional status. Anorexia and early satiety are additional problems associated with PUD. 2. The patient is not at increased risk for a sleep problem such as insomnia. 3. The patient is not at increased risk for ongoing pain. 4. The patient is not at increased risk for overhydration. Page Ref: 722 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

34 ..

35) A patient who is recovering from surgery for stomach cancer a month ago continues to experience dumping syndrome. What should the nurse instruct this patient? 1. "It's usually self-limiting and will resolve within 6 to 12 months." 2. "It will be a problem for the rest of your life." 3. "There's no treatment." 4. "Eat only a clear-liquid diet." Answer: 1 Explanation: 1. Dumping syndrome is typically self-limiting and lasts 6 to 12 months after surgery; however, a small percentage of people continue to experience long-term symptoms. 2. A small percentage of postoperative patients may continue to have dumping syndrome. 3. Treatment options for dumping syndrome include dietary modifications. 4. A clear-liquid diet is not recommended as a treatment for postoperative dumping syndrome. Page Ref: 728 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

35 ..

36) A patient who had stomach cancer surgery 2 years ago is concerned about it recurring because of being fatigued. Which health problem should the nurse realize this patient is experiencing? 1. Vitamin deficiency 2. A return of the stomach cancer 3. Metastasis 4. Ineffective coping Answer: 1 Explanation: 1. The cells of the stomach produce intrinsic factor, which is required for the absorption of vitamin B12. Vitamin B12 deficiency leads to pernicious anemia. Because of hepatic stores of vitamin B12, symptoms of anemia may not be seen for 1 to 2 years after surgery. 2. There are no clinical manifestations presented to support the recurrence of the cancer. 3. There are no clinical manifestations presented to support metastasis of the cancer. 4. The patient is seeking clarification of the condition, not demonstrating an inability to cope. Page Ref: 728 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

36 ..

37) A patient who has had gastric surgery for cancer is denying the diagnosis of cancer. What should the nurse do? 1. The nurse should not argue with the patient but continue to provide emotional support as needed. 2. The nurse should remind the patient of the diagnosis. 3. The nurse should ask a clinical psychologist to talk with the patient. 4. The nurse should explain how many people with cancer live long, productive lives. Answer: 1 Explanation: 1. A patient with the diagnosis of cancer may be in denial. The nurse should not negate denial if present because it is a coping mechanism that protects the patient from hopelessness. 2. There is no real need to remind the patient of the diagnosis. The patient is acting in a manner that can often be anticipated. 3. At this point, there is no need for a clinical psychologist to intervene. Making a referral to a clinical psychologist is beyond the duties of the nurse. 4. The patient is not emotionally prepared to discuss cancer survival at this time. Page Ref: 729 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

37 ..

38) An older patient is experiencing significant weight loss and has poorly fitting dentures that cause severe oral sores. When preparing the plan of care, which intervention will be most beneficial to the patient? 1. Providing analgesics as needed 2. Evaluating the need for assistive devices 3. Serving meals in an attractive environment 4. Offering assistance to eat Answer: 1 Explanation: 1. The patient with oral ulcerations is uncomfortable. Eating will be difficult if pain is not managed. 2. There is no indication the patient is in need of assistive devices. 3. An attractive environment is beneficial for all patients but is not the greatest physiological priority for this patient. 4. There is no indication this patient is unable to eat without help. Page Ref: 700 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 23.2 Describe the pathophysiology and manifestations of disorders of the mouth, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

38 ..

39) The nurse suspects that a patient receiving dronabinol (Marinol) to treat nausea and vomiting caused by chemotherapy is experiencing adverse effects of the medication. What did the nurse assess to come to this conclusion? Select all that apply. 1. Urine output 50 mL/hr 2. Blood pressure 88/62 mmHg 3. Complaints of extreme hunger 4. Heart rate 112 beats per minute 5. Oxygen saturation 96% on room air Answer: 2, 4 Explanation: 1. A urine output of 50 mL/hr is normal. 2. Hypotension is a possible side effect of dronabinol (Marinol). 3. Extreme hunger is not an adverse reaction to dronabinol (Marinol). 4. Tachycardia is a possible side effect of dronabinol (Marinol). 5. Oxygen saturation of 96% on room air is not an adverse effect of dronabinol (Marinol). Page Ref: 695 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

39 ..

40) A 32-year-old patient receiving chemotherapy for breast cancer is prescribed aprepitant (Emend). What should the nurse emphasize when teaching the patient about this medication? Select all that apply. 1. Take this medication for 10 days. 2. Take the medication either with food or on an empty stomach. 3. Use a barrier contraceptive while taking this medication. 4. A skin rash is an expected effect of this medication. 5. Contact the healthcare provider about any onset of confusion. Answer: 2, 3, 5 Explanation: 1. This medication should be taken for 3 days. 2. This medication can be taken with food or on an empty stomach. 3. The patient should use barrier contraception while taking this drug because oral contraceptives will be less effective. 4. A skin rash is an adverse effect and should be reported to the healthcare provider. 5. Confusion is an adverse effect and should be reported to the healthcare provider. Page Ref: 694 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 23.1 Describe the pathophysiology and manifestations of nausea and vomiting, and outline the interprofessional care and nursing care of patients with nausea and vomiting. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

40 ..

41) A patient with severe esophageal spasms is diagnosed with achalasia. For which surgical procedure should the nurse prepare teaching for this patient? Select all that apply. 1. Esophagectomy 2. Gastric resection 3. Laparoscopic myotomy 4. Balloon dilation of the lower esophageal sphincter 5. Endoscopically guided injection of botulinum toxin Answer: 3, 4, 5 Explanation: 1. An esophagectomy is indicated for esophageal cancer. 2. Gastric resection is indicated for gastric cancer. 3. Treatment of achalasia may include laparoscopic myotomy to reduce pressure and relieve symptoms. 4. Treatment of achalasia may include balloon dilation of the lower esophageal sphincter. Balloon dilation tears muscle fibers in the LES, reducing its pressure. 5. Treatment of achalasia may include endoscopically guided injection of botulinum toxin into the lower esophageal sphincter. Botulinum toxin injection lowers LES pressure, but may need to be repeated every 6 to 9 months. Page Ref: 710 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 23.3 Describe the pathophysiology and manifestations of disorders of the esophagus, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper gastrointestinal disorders.

41 ..

42) The nurse suspects that a patient is exhibiting manifestations of Zollinger-Ellison syndrome. What did the nurse assess to make this clinical judgment? Select all that apply. 1. Nausea 2. Diarrhea 3. Belching 4. Steatorrhea 5. Abdominal pain Answer: 2, 4 Explanation: 1. Nausea is not a manifestation of Zollinger-Ellison syndrome. 2. The peptic ulcers of Zollinger-Ellison syndrome may affect any portion of the stomach or duodenum, as well as the esophagus or jejunum. The high levels of hydrochloric acid entering the duodenum may cause diarrhea. 3. Belching is not a manifestation of Zollinger-Ellison syndrome. 4. The peptic ulcers of Zollinger-Ellison syndrome may affect any portion of the stomach or duodenum, as well as the esophagus or jejunum. The high levels of hydrochloric acid entering the duodenum may cause steatorrhea from impaired fat digestion and absorption. 5. Abdominal pain is not a manifestation of Zollinger-Ellison syndrome. Page Ref: 719 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 23.4 Describe the pathophysiology and manifestations of disorders of the stomach and duodenum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper gastrointestinal disorders.

42 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 24 Nursing Care of Patients with Bowel Disorders 1) The nurse is preparing to assess a patient with diverticulitis. Which area of the patient's abdomen should the nurse expect to palpate a mass? 1. Upper-right quadrant 2. Lower-left quadrant 3. Area of McBurney point 4. Epigastric region Answer: 2 Explanation: 1. A mass in the upper-right quadrant could involve a disorder of the liver or transverse colon. 2. Diverticulitis can manifest as a palpable mass in the lower-left quadrant as a result of the inflammatory response. 3. McBurney point is palpated to elicit rebound tenderness pain characteristic of appendicitis. 4. A mass in the epigastric region could indicate a disorder of the stomach or pancreas. Page Ref: 778 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

1 ..

2) A patient is prescribed a low-residue diet. What foods should the nurse instruct the patient to avoid while on this diet? 1. Wine, vinegar, beer, liquor 2. Rice, grains, pasta 3. Canned vegetables 4. Chilled fruit gelatin desserts Answer: 1 Explanation: 1. Alcohol is not permitted on a low-residue diet. 2. Foods allowed on a low-residue diet include rice, grains, and pasta. 3. Foods allowed on a low-residue diet include canned vegetables. 4. Foods allowed on a low-residue diet include chilled fruit gelatin desserts. Page Ref: 774 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

2 ..

3) A patient tells the nurse about diarrhea after eating ice cream. Which health problem should the nurse suspect this patient is experiencing? 1. Disease of the colon 2. Inflammation of the small intestines 3. Cholera 4. Lactose intolerance Answer: 4 Explanation: 1. There is not enough information to suspect colon disease. 2. The symptom of diarrhea after ingesting ice cream is inconsistent with small intestine inflammation. 3. The symptom does not suggest cholera. 4. When the lactose in milk is not broken down and absorbed, the lactose molecules exert an osmotic draw, which causes diarrhea. Page Ref: 783 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.4 Describe the pathophysiology and manifestations of malabsorption disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

3 ..

4) The nurse is providing care to a patient admitted with acute diarrhea. What intervention would assist in this patient's care? 1. Provide a normal diet as tolerated. 2. Hold all medications until the diarrhea stops. 3. Provide clear liquids in small amounts. 4. Encourage normal activities of daily living in the hospital room. Answer: 3 Explanation: 1. This patient should have limited food intake, reintroducing solid foods slowly. 2. The nurse should provide antidiarrheal medication as prescribed. 3. Fluid replacement is of primary importance in managing the patient with diarrhea. Solid food is withheld in the first 24 hours of acute diarrhea to rest the bowel. 4. Because of the potential for orthostatic hypotension, this patient should be instructed to move slowly and not engage in normal activities of daily living until the blood pressure is assessed. Page Ref: 738 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

4 ..

5) The nurse is caring for a patient with a fecal impaction. Which type of enema will best assist in relieving the fecal impaction? 1. Normal saline 2. Oil retention 3. Tap water 4. Soap suds Answer: 2 Explanation: 1. The normal saline enema is used to soften the fecal mass and promote defecation in the least irritating manner. 2. Oil retention enemas instill mineral or vegetable oil into the bowel to soften the fecal mass. The instilled oil is retained overnight or for several hours before evacuation. This is the most suitable choice for the patient with fecal impaction. 3. Tap water enemas soften the bowel and irritate the bowel to promote defecation. 4. Soap suds provide an increased means to irritate the bowel to promote a bowel movement. Page Ref: 743 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

5 ..

6) A patient with irritable bowel syndrome (IBS) asks why medication was prescribed to treat depression. Which response should the nurse make? 1. "Didn't the doctor tell you that you are depressed?" 2. "Depression can be caused by irritable bowel syndrome." 3. "Did the doctor not give you an opportunity to ask questions?" 4. "These medications help with the symptoms associated with your bowel problem." Answer: 4 Explanation: 1. There is no indication the patient is depressed. 2. Bowel disorders do not usually cause depression. 3. The patient is asking for clarification, and this response does not address the patient's concern. 4. Antidepressant drugs, including tricyclics and selective serotonin reuptake inhibitors (SSRIs), may help relieve abdominal pain associated with IBS. Page Ref: 745 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with bowel disorders.

6 ..

7) The nurse is implementing a bowel training program for a patient. What should be included in this patient's plan of care? 1. Assess the patient to determine the best time of day to use the commode for defecation. 2. Keep the bedpan near the patient at all times. 3. Instruct the patient not to attempt to use the bathroom unattended. 4. Stay with the patient while defecating. Answer: 1 Explanation: 1. Placing the patient in a normal position to defecate at a consistent time of day stimulates the defecation reflex and helps reestablish a pattern of stool evacuation. Ideally, the bowel training program should focus on use of the commode or toilet. 2. Ideally, the bowel training program should focus on use of the commode or toilet. 3. Providing the patient with assistance to the bathroom is a safety measure and does not influence the success of the bowel training program. 4. Remaining with the patient may reduce comfort level and interfere with defecation. Page Ref: 748 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

7 ..

8) A patient comes into the emergency department with suspected appendicitis. What should the nurse do for this patient? 1. Provide a hot water bottle to place over the abdomen. 2. Provide with clear water to drink. 3. Inspect the abdomen and assess bowel sounds. 4. Prepare to administer a biscodyl (Dulcolax) suppository. Answer: 3 Explanation: 1. No heat should be applied to the abdomen; this may increase circulation to the appendix and also cause perforation. 2. Keep the patient with suspected appendicitis NPO. 3. Assessing the abdomen and bowel sounds is the priority action for the nurse to take. 4. Do not administer laxatives or enemas, which may cause perforation of the appendix. Page Ref: 752 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

8 ..

9) The nurse can detect no bowel sounds on a patient recovering from bowel surgery. What should the nurse suspect is occurring in this patient? 1. Borborygmi 2. Paralytic ileus 3. Hyperactive bowel sounds 4. Atonic bowel Answer: 2 Explanation: 1. Borborygmi are loud, hyperactive bowel sounds. 2. Paralytic ileus, or ileus, is defined as an impaired propulsion or forward movement of bowel contents. The patient will not have bowel sounds upon auscultation. 3. Hyperactive bowel sounds are an increase in sound and frequency. 4. Atonic is a term used to refer to the loss of muscular tone. Page Ref: 754 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

9 ..

10) A patient is diagnosed with gastroenteritis. The nurse should assess which serum laboratory value first? 1. Sodium 2. Bicarbonate 3. Calcium 4. Potassium Answer: 4 Explanation: 1. Although electrolyte and acid‒base imbalances may result from gastroenteritis and extensive vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach, sodium would not be the first lab value assessed by the nurse. 2. Although electrolyte and acid‒base imbalances may result from gastroenteritis and extensive vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach, bicarbonate would not be the first lab value assessed by the nurse. 3. Although electrolyte and acid‒base imbalances may result from gastroenteritis and extensive vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach, calcium would not be the first lab value assessed by the nurse. 4. Electrolyte and acid‒base imbalances may result from gastroenteritis. Extensive vomiting can lead to metabolic alkalosis due to the loss of hydrochloric acid from the stomach. When diarrhea predominates, metabolic acidosis is more likely. Potassium is lost in either case, which leads to hypokalemia. Page Ref: 758 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

10 ..

11) After a company barbecue three people out of a group of 12 developed signs of enteritis. Which assessment finding should the nurse use as an indication of the source of the health problem? 1. The three patients ate hamburgers. 2. Nine people ate hotdogs. 3. Most of the people drank canned soda. 4. All of the people ate ice cream. Answer: 1 Explanation: 1. The highly pathogenic E. coli serotype O157:H7 is present in the gut of infected animals. Meats from the animal may be contaminated with bowel contents. The organism is readily destroyed by heat, so cuts of meat such as steaks or roasts are less likely to cause infection, since the organism is on the outside of the meat. However, the process of grinding hamburger allows E. coli to be mixed throughout the meat. 2. Hotdogs are not associated with the bacteria. 3. Canned soda is not associated with the bacteria. 4. Ice cream is not associated with the bacteria. Page Ref: 761 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

11 ..

12) A young adult female patient is diagnosed with inflammatory disease of the small bowel. Which health problem is this patient most likely experiencing? 1. Ulcerative colitis 2. Chronic diarrhea 3. Gastroenteritis 4. Crohn disease Answer: 4 Explanation: 1. Ulcerative colitis affects the large intestine. 2. A diagnosis of chronic diarrhea is not supported by the information provided. The diarrhea associated with Crohn disease is frequent, causing watery stools several times a day. 3. Gastroenteritis results from ingesting contaminated foods or beverages. 4. In Crohn disease, a patchy pattern of involvement is seen, which affects primarily the small intestine. The peak incidence is in adolescents and young adults between the ages of 15 and 30 years. Page Ref: 764 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

12 ..

13) A patient with Crohn disease is recovering from a bowel resection. What does the nurse realize will most likely occur in this patient? 1. The patient will never have another recurrence of the disease. 2. The patient will possibly have a recurrence in another portion of the bowel. 3. The patient will develop ulcerative colitis. 4. The patient will experience intestinal strictures. Answer: 2 Explanation: 1. The disease process for Crohn disease tends to recur in other areas following removal of affected bowel segments. 2. The disease process for Crohn disease tends to recur in other areas following removal of affected bowel segments. 3. The processes involving Crohn disease and ulcerative colitis are different. 4. There is no increased risk for the development of intestinal strictures. Page Ref: 771 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with bowel disorders.

13 ..

14) A patient with Crohn disease is experiencing weight loss. What should be included in this patient's plan of care? 1. A low-calorie, high-milk diet 2. A low-calorie, low-residue diet 3. A high-calorie, low-protein diet 4. A high-calorie, low-fat diet Answer: 4 Explanation: 1. Provide a high-kilocalorie, high-protein, and low-fat diet and restrict milk and milk products if lactose intolerance is present. 2. The Crohn patient needs an elevation in calories related to the nutrients lost as a result of diarrhea. 3. The DASH diet is appropriate for the patient wanting to lower elevated blood pressure. 4. Provide a high-kilocalorie, high-protein, and low-fat diet, and restrict milk and milk products if lactose intolerance is present. The Crohn patient needs an elevation in calories related to the nutrients lost as a result of diarrhea. Page Ref: 775 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

14 ..

15) A patient is suspected as having sprue. What diet teaching does this patient need? 1. Avoid high-protein foods. 2. A vegetarian diet is the best treatment for this condition. 3. Gluten products must be eliminated from the diet. 4. All whey products must be eliminated from the diet. Answer: 3 Explanation: 1. Avoiding high-protein foods is not relevant for the patient with sprue. 2. A vegetarian diet is not relevant for the patient with sprue. 3. The patient with celiac sprue is placed on a gluten-free diet. This treatment is generally successful, as long as the patient entirely avoids gluten. 4. The elimination of whey is not relevant for the patient with sprue. Page Ref: 782 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.4 Describe the pathophysiology and manifestations of malabsorption disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

15 ..

16) A patient who is newly diagnosed with short bowel syndrome asks what can be done to help the problem. How should the nurse respond to this patient? 1. "Dealing with this problem will be difficult in the beginning." 2. "Sometimes minor diet changes will alleviate the problem." 3. "I think more surgery is in your future." 4. "Short bowel syndrome is a long-term challenge." Answer: 2 Explanation: 1. Advising the patient there will initially be difficulty promotes negativity and may not be correct information. 2. Management of short bowel syndrome focuses on alleviating symptoms. Patients often simply require frequent, small, high-kilocalorie, and high-protein feedings. 3. Surgery is not utilized to manage short bowel syndrome. 4. Advising the patient it will be a lifelong challenge does not address the verbalized concerns. Page Ref: 784 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.4 Describe the pathophysiology and manifestations of malabsorption disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

16 ..

17) A patient with cancer of the rectum is scheduled for surgery and the placement of a permanent ostomy. Which type of ostomy will this patient most likely have performed during the surgery? 1. Ileostomy 2. Double-barrel 3. Sigmoid 4. Transverse loop Answer: 3 Explanation: 1. The ileostomy is not in the correct area to manage cancer in this location. 2. The double-barrel ostomy is not in the correct area to manage cancer in this location. 3. A sigmoid colostomy is the most common permanent colostomy performed, particularly for cancer of the rectum. It is usually created during an abdominoperineal resection. 4. The transverse loop ostomy is not in the correct area to manage cancer in this location. Page Ref: 788 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.5 Describe the pathophysiology and manifestations of neoplastic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with bowel disorders.

17 ..

18) A patient is being seen for a "sudden lump" in the groin after lifting a heavy box to a shelf. Which health problem should the nurse suspect is occurring with this patient? 1. Indirect inguinal hernia 2. Direct inguinal hernia 3. Femoral hernia 4. Incisional hernia Answer: 1 Explanation: 1. Indirect inguinal hernias are caused by improper closure of the tract that develops as the testes descend into the scrotum before birth. A sac of abdominal contents protrudes through the internal inguinal ring into the inguinal canal. It often descends into the scrotum. Although indirect inguinal hernias are congenital defects, they often are not evident until adulthood, when increased intra-abdominal pressure and dilation of the inguinal ring allow abdominal contents to enter the channel. 2. Direct inguinal hernias are acquired defects that result from weakness of the posterior inguinal wall and a palpable mass may be present in the groin. Direct inguinal hernias usually affect older adults. 3. Femoral hernias are also acquired defects in which a peritoneal sac protrudes through the femoral ring. 4. Inadequate information is provided to support the presence of an incisional hernia. Page Ref: 795 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6 Describe the pathophysiology and manifestations of structural and obstructive bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

18 ..

19) A patient learns that a small bowel obstruction was caused by an appendectomy five years ago. Which health problem most likely is causing the obstruction? 1. An untreated infection of the appendix 2. Adhesions 3. Undiagnosed femoral hernia 4. Umbilical hernia Answer: 2 Explanation: 1. An untreated infection would have resulted in peritonitis. 2. In adults, adhesions develop following abdominal surgery or inflammatory processes. Adhesions usually produce a simple obstruction or single blockage in one portion of the intestine. 3. There is inadequate information provided to support a femoral hernia. 4. There is inadequate information provided to support an umbilical hernia. Page Ref: 797 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.6 Describe the pathophysiology and manifestations of structural and obstructive bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

19 ..

20) The nurse is providing medications to a patient with diverticular disease. Which medication should the nurse question for this patient? 1. Docusate (Colace) 2. Metronidazole (Flagyl) 3. Trimethoprim-sulfamethoxazole (Bactrim) 4. Bisacodyl (Dulcolax) suppository Answer: 4 Explanation: 1. Although a stool softener such as docusate (Colace) may be prescribed, it is important to note that laxatives can further increase intraluminal pressure in the colon and should be avoided for the patient with diverticular disease. 2. Systemic broad-spectrum antibiotics effective against usual bowel flora are prescribed to treat acute diverticulitis. Oral antibiotics such as metronidazole (Flagyl) may be prescribed if manifestations are mild. 3. Systemic broad-spectrum antibiotics effective against usual bowel flora are prescribed to treat acute diverticulitis. Oral antibiotics such as trimethoprim-sulfamethoxazole (Septra, Bactrim) may be prescribed if manifestations are mild. 4. Although a stool softener such as docusate (Colace) may be prescribed, it is important to note that laxatives can further increase intraluminal pressure in the colon and should be avoided for the patient with diverticular disease. Page Ref: 778 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with bowel disorders.

20 ..

21) The nurse is asked to "look at" a patient because "something is coming out" of the rectum. Which health problem is the patient most likely experiencing? 1. Internal hemorrhoids 2. Colostomy 3. Prolapsed hemorrhoids 4. Femoral hernia Answer: 3 Explanation: 1. Internal hemorrhoids are not visible by an external examination. 2. The colostomy and femoral hernia are not located in the rectal area. 3. Prolapsed hemorrhoids will be visible from the rectum and anal area. 4. The colostomy and femoral hernia are not located in the rectal area. Page Ref: 801 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.7 Describe the pathophysiology and manifestations of anorectal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

21 ..

22) The nurse is providing discharge instructions to a patient who is recovering from anal-rectal surgery for repair of an anal fissure. What should be included in these instructions? Select all that apply. 1. Do not remove the dressing. 2. Change the dressing if it becomes soiled with urine or feces. 3. Use the sitz bath. 4. Use the antibiotic until all drainage stops. 5. Avoid bowel movements. Answer: 2, 3 Explanation: 1. Teach the patient to keep the perianal region clean and dry. If a dressing is in place, instruct to avoid soiling it with urine or feces during elimination. 2. Teach the patient to keep the perianal region clean and dry. If a dressing is in place, instruct to avoid soiling it with urine or feces during elimination. 3. Discuss the use of sitz baths for cleaning and comfort. 4. If an antibiotic has been prescribed, provide written and verbal instructions about its use, its desired effects, and possible adverse effects and their management. 5. Teach the importance of maintaining a high-fiber diet and liberal fluid intake to increase stool bulk and softness and thereby decrease discomfort with defecation. Stress the importance of responding to the urge to defecate to prevent constipation. Page Ref: 804 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.7 Describe the pathophysiology and manifestations of anorectal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

22 ..

23) A patient who is experiencing diarrhea associated with a microorganism asks why antidiarrheal medication is not to be used. What should the nurse respond to this patient? 1. "Antidiarrheal medication slows down the elimination of the microorganism causing the diarrhea." 2. "Antibiotics are always used to treat the microorganisms but antibiotics may worsen diarrhea." 3. "The potassium you are taking will help to slow down the diarrhea." 4. "Your physician does not like to use antidiarrheal medications." Answer: 1 Explanation: 1. Antidiarrheal medications can prolong the discomfort by slowing the elimination of the bacteria from the bowel. 2. Antibiotics may be given but the antibiotics alter the normal flora of the bowel and may worsen diarrhea. 3. Potassium is given to achieve electrolyte balance. 4. This response does not address the patient's question. Page Ref: 737 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

23 ..

24) The nurse has instructed the patient who is experiencing diarrhea associated with irritable bowel syndrome on dietary changes to prevent diarrhea. Which menu selection indicates that patient teaching was effective? 1. Yogurt, crackers, and sweet tea 2. Salad with chicken, whole wheat crackers 3. Bacon, tomato, lettuce with mayonnaise, and a soft drink 4. Tuna on white bread and green grapes Answer: 2 Explanation: 1. Dairy increases diarrhea. Foods high in carbohydrates increase diarrhea. 2. Salad and whole wheat crackers may decrease diarrhea due to increased fiber. 3. Bacon, tomato, lettuce with mayonnaise and soft drink is high in fat and the soft drink is hyperosmolar, both contributing to diarrhea. 4. Foods high in carbohydrates increase diarrhea. Green grapes may increase diarrhea. Page Ref: 738 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

24 ..

25) A patient with peritonitis develops a temperature of 103°F (39.4°C), is restless, has blood pressure of 85/45 mmHg and has a urinary output of 76 mL in 8 hours. For which health problem should the nurse plan care for this patient? 1. Hypovolemic shock 2. Inflammation 3. Third spacing 4. Bowel dysfunction Answer: 1 Explanation: 1. The patient experiencing peritonitis may develop an abscess, which can lead to shock. The patient developing shock may present with oliguria, hypotension, fever, restlessness, confusion, and hypovolemia. 2. The symptoms do not indicate inflammation. 3. The symptoms do not indicate third spacing. 4. The symptoms do not indicate bowel dysfunction. Page Ref: 754 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

25 ..

26) The nurse determines that a patient taking metronidazole (Flagyl) for a protozoan infection has been drinking alcohol while taking the medication. What assessment finding did the nurse use to make this clinical decision? Select all that apply. 1. Bruising 2. Flushing 3. Vomiting 4. Sore throat 5. Severe headache Answer: 2, 3, 5 Explanation: 1. Bruising is an adverse effect of metronidazole (Flagyl) and should be reported to the healthcare provider. 2. Alcohol causes an Antabuse-type reaction when taking metronidazole (Flagyl). Flushing is one manifestation of this response. 3. Alcohol causes an Antabuse-type reaction when taking metronidazole (Flagyl). Vomiting is one manifestation of this response. 4. Sore throat is an adverse effect of metronidazole (Flagyl) and should be reported to the healthcare provider. 5. Alcohol causes an Antabuse-type reaction when taking metronidazole (Flagyl). Severe headache is one manifestation of this response. Page Ref: 762 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

26 ..

27) A patient recovering from surgery for a small bowel obstruction is prescribed enteral feedings. Which action should the nurse take to ensure the feedings are provided safely to the patient? Select all that apply. 1. Keep the head of the bed elevated 30 to 45 degrees. 2. Check for tube placement by flushing with normal saline. 3. Flush the tube with club soda after administering medications. 4. Measure external tube length after verifying placement with an x-ray. 5. Stop the tube feeding 10 minutes before changing the position to supine. Answer: 1, 4 Explanation: 1. The head of the bed should be elevated 30 to 45 degrees. 2. Flushing with normal saline is not an appropriate method to check for tube placement. 3. Flushing the tube with club soda after medication administration is not appropriate. 4. The external tube length should be measured after placement has been verified with an xray. 5. Tube feedings should be stopped 30 to 60 minutes before placing the patient in the supine position. Page Ref: 755 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

27 ..

28) The nurse instructs a patient with irritable bowel syndrome about the newly prescribed medication sulfasalazine (Azulfidine). Which patient statement indicates that teaching has been effective? Select all that apply. 1. "I should take this medication before meals." 2. "I should use sunscreen while taking this medication." 3. "I should not take any aspirin while taking this medication." 4. "I should restrict my fluid intake while taking this medication." 5. "I should not take any vitamin C while taking this medication." Answer: 2, 3, 5 Explanation: 1. The patient should be instructed to take this medication after meals to decrease gastric distress. 2. This medication increases sensitivity to the sun, so sunscreen should be used. 3. This medication should not be taken with aspirin. 4. The patient should be instructed to drink at least 2 quarts of fluid each day to reduce the risk of kidney damage. 5. This medication should not be taken with vitamin C. Page Ref: 770 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

28 ..

29) A patient has been experiencing diarrhea for several days. What should the nurse assess to determine if adverse effects are occurring within this patient? Select all that apply. 1. Skin turgor 2. Muscle tone 3. Serum potassium level 4. Serum magnesium level 5. Orthostatic blood pressure Answer: 1, 3, 4, 5 Explanation: 1. The nurse should monitor skin turgor to identify and respond to possible adverse effects of diarrhea. 2. Muscle tone will not help identify possible adverse effects of diarrhea. 3. Water and electrolytes are lost in diarrheal stool. The nurse should monitor serum potassium level to help identify a possible adverse effect of diarrhea. 4. Water and electrolytes are lost in diarrheal stool. The nurse should monitor serum magnesium level to help identify a possible adverse effect of diarrhea. 5. Water is lost in the stool which can lead to dehydration. The nurse should monitor orthostatic vital signs to identify possible adverse effects of diarrhea. Page Ref: 736 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

29 ..

30) The nurse suspects that a patient with ulcerative colitis has taken a dose of diphenoxylate (Lomotil) to help with diarrhea. What did the nurse assess to make this clinical decision? Select all that apply. 1. Fever 2. Tachycardia 3. Hypotension 4. Low urine output 5. Abdominal cramps Answer: 1, 2, 3, 5 Explanation: 1. Toxic megacolon may be triggered by the use of laxatives by the person with ulcerative colitis. Manifestations of toxic megacolon include fever. 2. Toxic megacolon may be triggered by the use of laxatives by the person with ulcerative colitis. Manifestations of toxic megacolon include tachycardia. 3. Toxic megacolon may be triggered by the use of laxatives by the person with ulcerative colitis. Manifestations of toxic megacolon include hypotension. 4. Low urine output is not a manifestation of toxic megacolon. 5. Toxic megacolon may be triggered by the use of laxatives by the person with ulcerative colitis. Manifestations of toxic megacolon include abdominal cramps. Page Ref: 774 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

30 ..

31) A patient with chronic diarrhea has been advised by the healthcare provider to avoid foods containing sorbitol and mannitol. What should the nurse instruct the patient to avoid consuming for this health problem? Select all that apply. 1. Mints 2. Honey 3. Pear juice 4. Apple juice 5. Orange juice Answer: 1, 3, 4 Explanation: 1. Mints may contain sorbitol or mannitol, which are sugars that are not absorbed and can cause osmotic draw, increasing diarrhea. 2. Honey contains fructose. 3. Pear juice may contain sorbitol or mannitol, which are sugars that are not absorbed and can cause osmotic draw, increasing diarrhea. 4. Apple juice may contain sorbitol or mannitol, which are sugars that are not absorbed and can cause osmotic draw, increasing diarrhea. 5. Orange juice is not identified as a food item that aggravates chronic diarrhea. Page Ref: 738 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

31 ..

32) After learning that a patient has abdominal pain that occurs at least 3 days per month over the last 3 months, the nurse suspects that a patient is experiencing irritable bowel syndrome. Which characteristic of the patient's abdominal pain did the nurse use to make this clinical decision? Select all that apply. 1. Relieved by eating 2. Improves with defecation 3. Associated with a change in stool form 4. Associated with a change in bowel frequency 5. Improves with physical activity and limiting food intake. Answer: 2, 3, 4 Explanation: 1. Abdominal pain that is relieved by eating is not a characteristic of irritable bowel syndrome. 2. Improvement of abdominal pain with defection is one characteristic used to diagnose irritable bowel syndrome in a patient who has had abdominal pain or discomfort 3 days per month in the past 3 months. 3. A change in stool form is one characteristic used to diagnose irritable bowel syndrome in a patient who has had abdominal pain or discomfort 3 days per month in the past 3 months. 4. A change in bowel frequency is one characteristic used to diagnose irritable bowel syndrome in a patient who has had abdominal pain or discomfort 3 days per month in the past 3 months. 5. Abdominal pain that improves with physical activity and limiting food intake is not characteristic of irritable bowel syndrome. Page Ref: 745 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.1 Describe the pathophysiology and manifestations of disorders of motility, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with bowel disorders.

32 ..

33) The nurse is caring for an older patient recovering from a bleeding ulcer. Which manifestation should the nurse use to determine whether the patient is experiencing peritonitis? Select all that apply. 1. Confusion 2. Bradycardia 3. Restlessness 4. Abdominal discomfort 5. Decreased urinary output Answer: 1, 3, 4, 5 Explanation: 1. Patients who are older, chronically debilitated, or immunosuppressed may present with few of the classic signs of peritonitis. Increased confusion may be the only manifestation present. 2. Bradycardia is not a manifestation of peritonitis in an older patient. 3. Patients who are older, chronically debilitated, or immunosuppressed may present with few of the classic signs of peritonitis. Restlessness may be the only manifestation present. 4. Patients who are older, chronically debilitated, or immunosuppressed may present with few of the classic signs of peritonitis. Vague abdominal complaints may be the only manifestation present. 5. Patients who are older, chronically debilitated, or immunosuppressed may present with few of the classic signs of peritonitis. Decreased urinary output may be the only manifestation present. Page Ref: 754 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with bowel disorders.

33 ..

34) A patient receiving long-term antibiotic therapy for an infected joint replacement begins to experience diarrhea, abdominal cramps, malaise, fever, and anorexia. What intervention should the nurse prepare to administer to this patient? Select all that apply. 1. Maintain nothing by mouth status. 2. Prepare to administer metronidazole. 3. Insert a nasogastric tube for feedings. 4. Collect all urine for a 24-hour specimen. 5. Discontinue the currently prescribed antibiotic. Answer: 2, 5 Explanation: 1. Nothing by mouth status is not a treatment for Clostridium difficile. 2. The patient is demonstrating manifestations of Clostridium difficile. Treatment with metronidazole is specific for C. difficile. 3. A nasogastric tube for feedings is not a treatment for Clostridium difficile. 4. Collecting 24-hour urine is not indicated for Clostridium difficile. 5. The patient is demonstrating manifestations of Clostridium difficile. Stopping the antibiotic causing the diarrhea is the first step in the treatment of this health problem. Page Ref: 758 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 24.2 Describe the pathophysiology and manifestations of acute inflammatory and infectious bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with bowel disorders.

34 ..

35) The nurse teaches a patient with Crohn disease about surgery to create a continent ileostomy. Which patient statement indicates that teaching has been effective? Select all that apply. 1. "I will need to change my diet." 2. "Stool will collect in an internal pouch." 3. "Stool will not leak through the stoma." 4. "I will use a catheter to drain the stool." 5. "I will need to change the bag every day." Answer: 2, 3, 4 Explanation: 1. There is no evidence that the patient will need to change the diet for a continent ileostomy. 2. In a continent ileostomy, an intra-abdominal reservoir is constructed and a nipple valve formed from the terminal ileum before it is brought to the surface of the abdominal wall. Stool collects in the internal pouch. 3. In a continent ileostomy, an intra-abdominal reservoir is constructed and a nipple valve formed from the terminal ileum before it is brought to the surface of the abdominal wall. A nipple valve prevents stool from leaking through the stoma. 4. In a continent ileostomy, an intra-abdominal reservoir is constructed and a nipple valve formed from the terminal ileum before it is brought to the surface of the abdominal wall. A catheter is inserted into the pouch to drain the stool. 5. An ostomy bag does not need to be worn with a continent ileostomy. Page Ref: 772 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

35 ..

36) A patient with Crohn disease is instructed to ingest a low-residue diet. Which dietary choice indicates that the patient needs additional information about this eating plan? Select all that apply. 1. Corn flakes 2. Poppy seed roll 3. Tapioca pudding 4. Steamed broccoli 5. Whole grain bread Answer: 2, 4, 5 Explanation: 1. Cereals made from refined flours such as corn flakes are permitted on a lowresidue diet. 2. Raw or cooked seeds should be avoided on a low-residue diet. 3. Desserts such as tapioca are permitted on a low-residue diet. 4. Cooked vegetables are to be avoided on a low-residue diet. 5. Whole grain breads are to be avoided on a low-residue diet. Page Ref: 774 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

36 ..

37) An older patient is diagnosed with severe acute diverticulitis. What treatment should the nurse expect to be prescribed for this patient? Select all that apply. 1. Complete bed rest 2. Intravenous fluids 3. Nothing by mouth 4. Aspirin or NSAIDs for pain 5. Intravenous cefoxitin (Mefoxin) Answer: 2, 3, 5 Explanation: 1. There is no need for this patient to be on complete bed rest. 2. Severe, acute attacks of diverticulitis often necessitate hospitalization and treatment with intravenous fluids. 3. The patient initially may be NPO. 4. There is no specific recommendation for pain medications for acute diverticulitis. 5. Severe, acute attacks of diverticulitis often necessitate hospitalization and treatment with a second-generation cephalosporin such as cefoxitin (Mefoxin). Page Ref: 778 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 24.3 Describe the pathophysiology and manifestations of chronic inflammatory bowel disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with bowel disorders.

37 ..

38) A patient with malabsorption syndrome is prescribed vitamin B12 injections. Which manifestation of this health problem should the nurse expect to improve with this vitamin supplement? Select all that apply. 1. Anemia 2. Cheilosis 3. Bone pain 4. Paresthesias 5. Muscle cramps Answer: 1, 2, 4, 5 Explanation: 1. One systemic manifestation of malabsorption syndrome is anemia. Vitamin B 12 will help with erythropoiesis. 2. One systemic manifestation of malabsorption syndrome is cheilosis. Vitamin B12 will help with this manifestation. 3. Bone pain is associated with vitamin D and calcium deficiency. 4. One systemic manifestation of malabsorption syndrome is paresthesias. Vitamin B12 will help with neurologic functioning. 5. One systemic manifestation of malabsorption syndrome is muscle cramps. Vitamin B12 will help with muscular functioning. Page Ref: 781 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 24.4 Describe the pathophysiology and manifestations of malabsorption disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

38 ..

39) A patient with a new descending colostomy is concerned because the stool is runny. Which food item should the nurse suggest to the patient to help thicken the stool? Select all that apply. 1. Peas 2. Pasta 3. Cheese 4. Bananas 5. Broccoli Answer: 2, 3, 4 Explanation: 1. Peas will not thicken the stool but will increase intestinal gas. 2. Pasta will thicken the stool. 3. Cheese will thicken the stool. 4. Bananas will thicken the stool. 5. Broccoli will not thicken the stool but will increase intestinal gas. Page Ref: 791 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 24.5 Describe the pathophysiology and manifestations of neoplastic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with bowel disorders.

39 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 25 Nursing Care of Patients with Gallbladder, Liver, and Pancreatic Disorders 1) The nurse is preparing instructions for a patient who is at risk for cholelithiasis. What lifestyle modification should the nurse include in this teaching? 1. Reduce sodium intake. 2. Increase fluids. 3. Reduce smoking. 4. Reduce fat consumption. Answer: 4 Explanation: 1. While all patients should be instructed to reduce sodium intake, this step would not assist in reducing cholelithiasis or its pain. 2. Increasing fluids would not assist in reducing cholelithiasis or its pain. 3. While all patients should cease smoking, there is no relationship between smoking and cholelithiasis. 4. Most gallstones consist primarily of cholesterol. Excess cholesterol in the bile is associated with obesity and a high-calorie, high-cholesterol diet. Page Ref: 815 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

1 ..

2) The nurse is assessing a patient who is experiencing hepatocellular failure. Which finding best indicates that the patient is developing ascites? 1. Accumulation of fluid in the abdomen 2. Jaundiced skin 3. Ecchymosis 4. Upper-right-quadrant pain Answer: 1 Explanation: 1. Ascites is the accumulation of the fluid in the abdomen and is a result of hepatocellular failure. 2. Jaundice is manifested as yellow-tinged skin and is the result of hepatic disorders. 3. The patient experiencing hepatic problems might have bleeding and bruising due to inadequate vitamin K. 4. Obstructed biliary flow could be the cause of upper-right-quadrant pain. Page Ref: 817 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

2 ..

3) A patient with hepatitis is receiving interferon alpha. Which manifestation indicates that the patient is experiencing an untoward effect of this medication? 1. Jaundice 2. Flulike syndrome 3. Gallbladder pain 4. Clay-colored stools Answer: 2 Explanation: 1. Jaundice is characterized by yellow-tinged skin as a result of hepatitis. 2. The patient who is receiving interferon alpha may experience flulike symptoms such as fever, fatigue, body aches, headache, and chills. 3. Gallbladder pain is the result of stones in the gallbladder. 4. Clay-colored stools are associated with liver or biliary disease. Page Ref: 822 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

3 ..

4) The nurse is teaching a patient about strategies for reducing the risk of hepatitis B transmission. Which patient statement indicates teaching has been effective? Select all that apply. 1. "I will wash my hands frequently to prevent fecal-oral transmission." 2. "I will avoid alcohol." 3. "I will avoid contact with blood and body fluids." 4. "I will avoid contaminated food and water." 5. "I will use safe sex techniques." Answer: 3, 5 Explanation: 1. Hepatitis A virus, not hepatitis B virus, is spread by fecal-oral transmission. 2. Cirrhosis is related to alcohol consumption and to chronic hepatitis B or C. 3. Hepatitis B is contracted through contaminated blood and body fluids. Strategies that reduce exposure to the blood and body fluids of others reduce the risk of hepatitis B transmission. 4. Hepatitis A virus, not hepatitis B virus, is spread through contaminated food and water. 5. Hepatitis B is contracted through contaminated blood and body fluids. Using safe sex techniques reduces the risk of hepatitis B transmission. Page Ref: 818 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

4 ..

5) A patient who has portal systemic encephalopathy is receiving Neomycin (neomycin sulfate). Which manifestation should indicate to the nurse that the patient's condition is improving? 1. Increase in potassium level

2. Asterixis 3. Relief of jaundice 4. Increased level of consciousness Answer: 4 Explanation: 1. Neomycin (neomycin sulfate) causes diarrhea, which decreases rather than increases potassium. 2. Asterixis, the downward flapping of the hands, is a sign of portal systemic encephalopathy and should improve with administration of Neomycin (neomycin sulfate). 3. Neomycin does not improve jaundice. 4. Portal systemic encephalopathy is characterized by impaired judgment, confusion, disorientation, and incoherence related to high level of ammonia in the blood. Administering Neomycin (neomycin sulfate) should reduce ammonia levels by decreasing the number of bacteria-producing microorganisms in the bowel. Page Ref: 831 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.

5 ..

6) The nurse is planning care for a patient scheduled for paracentesis to treat ascites. Which outcome should the nurse use for this patient's plan of care? 1. The patient will have normal bilateral breath sounds. 2. The patient's spleen will not rupture. 3. The patient's respiratory effort will be lessened. 4. The patient will not manifest symptoms of hepatomegaly. Answer: 3 Explanation: 1. Paracentesis does not alter breath sounds. 2. A ruptured spleen is not a complication of paracentesis. 3. The goal of paracentesis is to relieve respiratory distress caused by excess fluid in the abdomen. 4. Paracentesis does not cause an enlarged liver. Page Ref: 832 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

6 ..

7) The nurse is instructing a patient recovering from a liver transplant. What should the nurse include in this teaching? 1. Eat a high-protein diet. 2. Reduce scheduled antirejection drugs to every other day if nausea occurs. 3. Take acetaminophen (Tylenol) if fever develops. 4. Report sore throats to the healthcare provider. Answer: 4 Explanation: 1. The patient should be instructed to eat a low-to-moderate-protein diet to reduce the workload of the liver in terms of protein metabolism. 2. The patient must adhere to the prescribed medication schedule unless otherwise instructed by the healthcare provider. 3. Acetaminophen (Tylenol) should not be taken, as it is liver-toxic. 4. The patient who has undergone a liver transplant should be instructed to report any signs of infection, such as a sore throat, as the medications prescribed to prevent organ rejection increase the risk of contracting infectious diseases. Page Ref: 835 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

7 ..

8) A patient with pancreatitis asks why the stools are frothy and have a foul odor. Which response should the nurse make? 1. "This is a sign of malnutrition." 2. "This indicates your stools have more fat in them." 3. "This is a sign of peptic ulcer disease." 4. "You may be developing diabetes mellitus." Answer: 2 Explanation: 1. Pancreatitis can lead to malnutrition, but steatorrhea is not a sign of malnutrition. This statement is inaccurate. 2. Steatorrhea is fatty, frothy, smelly stools associated with pancreatitis. It is caused by a decrease in pancreatic enzyme secretion; fat in the GI tract is not absorbed properly and a greater than normal amount of fat is excreted in the stool, causing the symptoms of steatorrhea. 3. Peptic ulcer disease can be related to pancreatitis, but it is not related to steatorrhea. 4. Diabetes mellitus causes increased urine production and could be the result of pancreatitis, but it does not affect stool characteristics. Page Ref: 842 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

8 ..

9) The nurse is caring for a patient with chronic pancreatitis and a serum amylase level of 180 units/L. Which eating plan should the nurse instruct the patient to follow? 1. Low residue, no alcohol 2. Low fat, no alcohol 3. Low fat, no fiber 4. Mechanical soft Answer: 2 Explanation: 1. A low-residue diet is prescribed for patients experiencing bowel disorders. 2. After the serum amylase level returns to normal, the patient experiencing pancreatitis should be instructed to consume a diet low in fat with no alcohol. 3. Almost all patients should consume a low-fat diet, but most patients need increased fiber. 4. A mechanical soft diet is reserved for the patient who needs to conserve energy or has a mouth or dentition disorder. Page Ref: 843 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

9 ..

10) A patient with epigastric pain has a serum amylase level of 369 units/L. What should the nurse do? 1. Continue to monitor the patient. 2. Refer the patient to a dietician. 3. Contact the primary healthcare provider. 4. Question the patient regarding alcohol use patterns. Answer: 3 Explanation: 1. The patient could develop shock. 2. A dietitian is not needed at this time. 3. A normal level for serum amylase is between 0 and 130 units/L. In pancreatitis, the serum amylase increases to two to three times the normal level and remains elevated for 3 to 4 days. The primary healthcare provider should be notified of the patient's symptoms and the laboratory findings. 4. The nurse can assess the patient's alcohol intake at a later time. Page Ref: 843 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.

10 ..

11) The nurse is caring for a patient with a Sengstaken-Blakemore tube. Which assessment finding should the nurse immediately report for follow-up? 1. Left lower leg swollen and reddened 2. Absent bowel sounds to lower-left quadrant 3. Decreased level of consciousness 4. 3 cm darkened area on left heel Answer: 3 Explanation: 1. A swollen and reddened lower leg may indicate a venous thrombus. While this is a potentially serious problem, the possibility of another problem is the priority for follow-up. 2. Absent bowel sounds may indicate ileus. While this is a potentially serious problem, the possibility of another problem is the priority for follow-up. 3. The Sengstaken-Blakemore tube has two balloons, which are used to tamponade the esophageal bleeding. One balloon is in the stomach and the other is in the esophagus, and if the tube migrates, the airway can be obstructed. Decreased level of consciousness may indicate hypoxia and is the priority for follow-up. 4. A darkened area on the left heel may indicate a pressure ulcer. While this is a potentially serious problem, the possibility of another problem is the priority for follow-up. Page Ref: 833-834 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.

11 ..

12) The nurse notes new areas of ecchymosis on the arms and legs of a patient with liver cirrhosis. Which laboratory test result should the nurse monitor because of this finding? Select all that apply. 1. Complete blood count with platelets 2. Coagulation studies 3. Serum albumin 4. Serum ammonia levels 5. Serum hepatitis antibodies Answer: 1, 2 Explanation: 1. A CBC with platelets should be monitored. A low RBC count, hemoglobin, and hematocrit indicate anemia related to bone marrow suppression, increased RBC destruction, bleeding, and deficiencies of folic acid and vitamin B12. Platelets are low, related to increased destruction by the spleen. Leukopenia (low WBC count) also relates to splenomegaly. 2. Coagulation studies reveal the patient's tendency to bleed and the ability of the blood to clot and should be monitored. These studies show a prolonged prothrombin time due to impaired production of coagulation proteins and lack of vitamin K. 3. Albumin levels reflect liver impairment and/or nutritional status and are not related to risk for bleeding. 4. Serum ammonia levels elevate during liver failure due to the liver's inability to convert ammonia to urea for renal excretion. This test does not provide information regarding bleeding risk. 5. Testing for the presence of hepatitis antibodies in the blood does not provide information regarding coagulation. Page Ref: 836 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

12 ..

13) A patient has ascites caused by liver failure. Which finding should the nurse report for immediate follow-up? 1. Asterixis 2. Jaundice 3. Increased abdominal girth 4. Dyspnea Answer: 4 Explanation: 1. Asterixis or liver flap is a muscle tremor that interferes with the ability to maintain a fixed position of the extremities, causes involuntary jerking movements, and is an early sign of portal systemic encephalopathy. 2. Jaundice is a chronic problem with liver failure and does not present an immediate threat to the patient. 3. Increased abdominal girth is likely the result of ascites and may be contributing to the patient's shortness of breath. 4. Dyspnea is the immediate priority for this patient. Page Ref: 832 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

13 ..

14) A patient with cirrhosis is experiencing hypertension, edema, and shortness of breath. What should the nurse identify as the patient's priority problem? 1. Insufficient fluid level 2. Problem with tissue perfusion 3. Too much bodily fluid 4. Problem with integumentary status Answer: 3 Explanation: 1. Hypotension and dry mucous membranes are associated with a fluid volume deficit. 2. There is no evidence that the patient is having problems with tissue perfusion. 3. The patient with shortness of breath, edema, and hypertension is experiencing an excess amount of fluid. 4. Edema can cause an alteration in skin integrity, but there is no evidence of such problems in this patient. Page Ref: 829 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

14 ..

15) A patient with a liver abscess is experiencing nausea and vomiting. Which problem should the nurse identify as a priority for this patient? 1. Too much fluid 2. Not enough fluid 3. Problem breathing 4. Altered self-image Answer: 2 Explanation: 1. The patient with a liver abscess is at risk for developing dehydration due to fever, nausea, and vomiting as a result of the infection. The patient is likely not experiencing a problem with too much fluid. 2. The patient with a liver abscess is at risk for developing dehydration due to fever, nausea, and vomiting as a result of the infection. It is important that the nurse assess for signs of dehydration. 3. The patient with a liver abscess is not usually in respiratory distress. 4. There should be no problems with self-image, as the infection is in the liver. Page Ref: 840 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

15 ..

16) A patient experiences severe, steady pain in the epigastric area, nausea, and vomiting after eating barbecue ribs. What should the nurse consider as the most likely cause of the patient's symptoms? 1. Intolerance to pork 2. Obesity 3. Cholelithiasis 4. Pancreatitis Answer: 3 Explanation: 1. These symptoms are unrelated to porcine intolerance. 2. These symptoms are unrelated to obesity. 3. Symptoms of cholelithiasis (gallstone) include severe, steady pain in the epigastric region or upper-right quadrant of the abdomen. The pain may radiate to the back, right scapula, or shoulder. The pain often begins suddenly following a meal, and may last as long as 5 hours. It often is accompanied by nausea and vomiting. 4. These symptoms are unrelated to pancreatitis. Page Ref: 811 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

16 ..

17) A patient with cholelithiasis has a serum amylase level of 300 units/L. What should the nurse consider as the most likely explanation for the laboratory finding? 1. The gallstone is causing acute cholecystitis. 2. The gallstone has migrated to the neck of the pancreas. 3. The gallstone has caused bile to back into the pancreas. 4. The gallstone is blocking the common bile duct. Answer: 4 Explanation: 1. Acute cholecystitis does not elevate amylase levels. 2. It would be highly unlikely for the gallstone to migrate to the neck of the pancreas. 3. The gallstone does not cause bile to back into the pancreas, although it can cause pancreatic enzymes to back up into the pancreas. 4. When a gallstone in the bile duct blocks the common bile duct, pancreatic enzymes cannot exit the common bile duct and back up into the pancreas, causing pancreatitis, which elevates pancreatic enzymes. A normal serum amylase level is 30-170 units/L. Page Ref: 841 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

17 ..

18) The nurse is assessing a patient with cholelithiasis. Which patient statement indicates a progression to cholecystitis? Select all that apply. 1. "I've been in terrible pain for 2 hours." 2. "I'm hot and sweating, then cold and shivering." 3. "The pain's in the same location as when I had appendicitis." 4. "I need an emesis basin; I've vomited four times." 5. "My abdomen and my back both hurt." Answer: 2, 4, 5 Explanation: 1. The pain of acute cholecystitis usually lasts longer than that of biliary colic, continuing for 12 to 18 hours. 2. Descriptions of feeling hot and diaphoretic, then cold and shivering, should be recognized as describing a febrile state. Fever often is present in acute cholecystitis and may be accompanied by chills. 3. The pain related to cholecystitis is not located in the lower-right quadrant. 4. Nausea and vomiting are seen in acute cholecystitis. 5. Acute cholecystitis features pain that involves the entire upper-right quadrant (RUQ) and may radiate to the back, right scapula, or shoulder. Movement or deep breathing may aggravate the pain. Page Ref: 812 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

18 ..

19) The nurse has instructed a patient about the possible complications of unresolved cholecystitis. Which patient statement indicates that teaching has been effective? Select all that apply. 1. "I could have infected pus stored in my gallbladder." 2. "My gallbladder could rot and cause a big infection in my abdomen." 3. "A hole could form a connection between my gallbladder and intestines."' 4. "My intestines could be blocked with a gallstone." 5. "My gallbladder could turn inside out into the bile duct." Answer: 1, 2, 3, 4 Explanation: 1. Complications of cholecystitis include empyema, a collection of infected fluid within the gallbladder. 2. Gangrene and perforation with resulting peritonitis may occur. An abscess may form. 3. A fistula may form into an adjacent organ (such as the duodenum, colon, or stomach). 4. The small intestine may be obstructed by a large gallstone (gallstone ileus). 5. The gallbladder will not turn inside out into the bile duct. Page Ref: 812 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

19 ..

20) A patient has abdominal pain and a serum conjugated bilirubin level of 1.2 mg/dL. What should the nurse suspect is occurring with this patient? 1. A disease that requires phototherapy 2. A disorder that causes large amounts of red blood cell death 3. A disorder of the biliary system 4. A small bowel obstruction Answer: 3 Explanation: 1. Phototherapy is used in the care of a newborn. 2. The laboratory finding does not provide information to identify red blood cell death. 3. Elevated direct (conjugated) bilirubin may indicate obstructed bile flow in the biliary duct system. 4. The laboratory finding does not provide information to identify small bowel obstruction. Page Ref: 812 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

20 ..

21) A patient scheduled for a laparoscopic cholecystectomy asks the nurse why a surgical consent for a laparotomy must also be completed. How should the nurse respond? 1. "By signing both now, you'll never have to sign another one. We'll keep the extra on file for the future." 2. "Surgeons base their decision on whether to do the procedure laparoscopically or with a full incision on many factors. With this signed, the surgeon has options." 3. "You will be ready if the laparoscopic operating rooms are busy today." 4. "The surgeon will start the procedure laproscopically but may need to make an incision to complete the procedure." Answer: 4 Explanation: 1. Surgical consents are not signed in advance of procedures. 2. The consent is not intended to provide the surgeon with options. 3. The busyness of the operating rooms has nothing to do with the consent form. 4. There is a risk that a laparoscopic cholecystectomy may be converted to a laparotomy (surgical opening into the abdomen) during the procedure. Page Ref: 813 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.

21 ..

22) A patient has been given instructions about a laparoscopic cholecystectomy. Which patient statement indicates further teaching is needed? 1. "I should be able to go home within a day after the procedure." 2. "I will probably have bandages over the puncture sites." 3. "I am glad I won't need to have an open cholecystectomy." 4. "I will tell the nurse if I feel nauseated after surgery." Answer: 3 Explanation: 1. Patients are typically discharged within 24 hours. 2. The patient will likely have bandages over the puncture sites. 3. A patient with a laparoscopic cholecystectomy is at risk for needing an open cholecystectomy if the procedure cannot be completed laparoscopically due to complications. 4. Nausea is common after surgery and should be reported to the nurse. Page Ref: 813 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.

22 ..

23) The nurse is teaching a patient with an acute attack of cholecystitis about nutritional interventions. Which patient statement indicates additional teaching is required? 1. "I need to stop eating and drinking everything for a while." 2. "I may need a tube inserted into my nose that goes all the way into my stomach." 3. "I may be prescribed vitamins B and C." 4. "I may need extra bile salts to promote health." Answer: 3 Explanation: 1. Food intake may be eliminated during an acute attack of cholecystitis. 2. A nasogastric tube may be inserted to relieve nausea and vomiting. 3. If bile flow is obstructed, fat-soluble vitamins (A, D, E, and K) may need to be administered. 4. Bile salts may need to be administered. Page Ref: 813 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

23 ..

24) A patient wants to reduce the risk of developing gallstones and cholecystitis. What should the nurse instruct this patient? Select all that apply. 1. Walk for 30 minutes five times a week. 2. Eat a low-fiber, high-carbohydrate diet. 3. Eat unsaturated rather than saturated fats. 4. Eat a low-carbohydrate diet. 5. Lose weight by any means possible. Answer: 1, 3, 4 Explanation: 1. Physical activity can help reduce the incidence of cholelithiasis and cholecystitis. 2. A low-fiber, high-carbohydrate diet would not prevent the development of gallstones. 3. Eating a diet low on saturated fats helps reduce the risk for developing cholelithiasis and cholecystitis. 4. Eating a low-carbohydrate diet helps reduce the risk for developing cholelithiasis and cholecystitis. 5. The dangers of yo-yo dieting and extremely low-calorie diets should be reviewed with the patient. Page Ref: 815 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

24 ..

25) The nurse is teaching a patient about modifiable risk factors for cholelithiasis. What risk factor will the nurse discuss? Select all that apply. 1. Age 2. Obesity 3. Alternating weight loss and gain 4. Family history 5. Elevated serum cholesterol Answer: 2, 3, 5 Explanation: 1. Age is not a modifiable risk factor. 2. Obesity is a modifiable risk factor for cholelithiasis. 3. The patient should not lose and gain weight frequently. This is a modifiable risk factor. 4. Family history is not a modifiable risk factor. 5. Elevated serum cholesterol levels increase the risk for developing cholelithiasis. This is a modifiable risk factor. Page Ref: 815 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

25 ..

26) A patient scheduled for a laparoscopic cholecystectomy in 4 days asks how pain can be controlled until the surgery. How should the nurse respond? 1. "You will feel better if you sit in a recliner and drink water and try not to eat anything. Do not eat any fat." 2. "You will feel better if you rest in bed and do not eat anything until the procedure. Drink only water and milk." 3. "You will feel better if you alternate lying on your back and lying on your abdomen. You may eat anything except fatty food." 4. "You will feel better if you walk as frequently as possible. You may drink coffee, but not soda." Answer: 1 Explanation: 1. For greatest comfort the patient should sit in the Fowler's position, which reduces pressure on the inflamed gallbladder. A person in the Fowler's position is sitting straight up or leaning slightly back. The legs may be either straight or bent. Fat intake should be reduced to minimize gallbladder contractions and pain. 2. Resting in bed will not help with pain control before the surgery. Milk contains fat and should not be ingested. 3. Lying on the back and abdomen will not promote comfort. The patient should not eat anything during an acute episode of pain. 4. Walking is not recommended during a gallbladder attack. The patient should take nothing by mouth, including coffee. Page Ref: 814 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

26 ..

27) The patient with acute cholelithiasis asks why a nasogastric tube has to be inserted. Which should the nurse respond? 1. "You have not been able to follow your prescribed diet and exercise plan." 2. "We need to suck the bile out through your nose as it isn't going to your duodenum." 3. "Keeping your stomach empty allows your gallbladder to rest, reducing pain." 4. "The tube will prevent pancreatitis." Answer: 3 Explanation: 1. This is not the reason a nasogastric tube is placed. 2. This is not the reason a nasogastric tube is placed. 3. Emptying the stomach reduces the amount of chyme entering the duodenum and the stimulus for gallbladder contractions, thus reducing pain. 4. The nasogastric tube reduces nausea and vomiting; its use is not related to the prevention of pancreatitis. Page Ref: 813 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gallbladder, liver, and pancreatic disorders.

27 ..

28) A patient with acute cholecystitis is concerned about having the flu because of an oral temperature of 101.8°F. What should the nurse respond to the patient? 1. "Your cholecystectomy cannot be performed laparoscopically now." 2. "Tell me exactly what you ate for your last meal." 3. "Bacterial infection is often present in cholelithiasis." 4. "I will call the surgeon and ask to postpone the cholecystectomy." Answer: 3 Explanation: 1. The surgeon will make the determination about the type of surgery to be performed. 2. Asking about the last meal consumed is not relevant. 3. Bacterial infection is often present in acute cholecystitis and may cause an elevated temperature and respiratory rate. 4. Offering to call the surgeon to postpone surgery is not an appropriate response. Page Ref: 812 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

28 ..

29) The nurse is assessing the nutritional status of a patient who has cholelithiasis and a body mass index of 35. What action should the nurse take initially? 1. Ask the patient to discuss typical daily menu choices. 2. Ask the patient to discuss strategies used to manage weight. 3. Ask if the patient takes daily supplemental vitamin C. 4. Ask if the patient has been skipping meals to reduce gallbladder pain. Answer: 1 Explanation: 1. The nurse begins by assessing nutritional status, particularly diet history, height and weight, and skinfold measurements. 2. Even though often obese, patients with gallbladder disease may have an imbalanced diet. Discussing strategies used to manage weight may be important in assessing causes of cholelithiasis pain, as fluctuating weight gains and losses can contribute to cholelithiasis, but this is the not the priority when assessing the patient's nutritional status. 3. Vitamin C is a water-soluble vitamin. Fat-soluble vitamins might be deficient in the patient with cholelithiasis. 4. Asking if the patient has been skipping meals is important, but not as important as another aspect of nutritional status. Page Ref: 814 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

29 ..

30) A patient with an acutely inflamed gallbladder states that the pain has suddenly stopped. The patient wants to go home. What is the nurse's best response? 1. "It is your choice. You are feeling better and not required to stay." 2. "Please stay until your healthcare provider sees you tomorrow." 3. "I will inform your healthcare provider of the change in your symptoms." 4. "Yes, as soon as we perform the prescribed ultrasound of the gallbladder." Answer: 3 Explanation: 1. This is a dangerous response. The patient could be developing peritonitis. 2. The patient needs to be seen by the healthcare provider now. 3. Rupture of an acutely inflamed gallbladder may be heralded by abrupt but transient pain relief as contents are released from the distended gallbladder into the abdomen. This change should be promptly reported to the healthcare provider. 4. The ultrasound can wait. The change in symptoms needs to be reported immediately. Page Ref: 814 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.1 Describe the pathophysiology and manifestations of gallbladder disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

30 ..

31) A patient with liver failure is taking lactulose (Chronulac). Which laboratory data indicates that the medication is having the desired effect? 1. Increased serum ammonia level 2. Decreased serum ammonia level 3. Increased serum ALT level 4. Decreased serum ALT level Answer: 2 Explanation: 1. This medication does not increase the serum ammonia level. 2. Ammonia, a toxic by-product of protein metabolism, is converted to urea in the liver for elimination by the kidneys. Lactulose works by acidifying the contents of the bowel, which has the effect of keeping ammonia in the bowel, where it is excreted from the body in the stools, rather than being reabsorbed into the circulation. 3. This medication does not affect the ALT level. 4. This medication does not affect the ALT level. Page Ref: 831 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

31 ..

32) The nurse is assessing a patient with liver cirrhosis. Which findings should the nurse relate to the patient's failed liver function? Select all that apply. 1. The patient had two episodes of epistaxis. 2. The patient had toxic levels of a prescribed medication. 3. The patient is oriented to person and place but not to time. 4. The patient's urinary output has decreased. 5. The patient has cholelithiasis. Answer: 1, 2, 3 Explanation: 1. The liver produces clotting factors. Two episodes of epistaxis are likely related to the patient's liver failure. 2. The liver metabolizes medications. Toxic levels of prescribed medication in the absence of other factors are likely related to liver failure. 3. The patient who is disoriented may be experiencing high serum ammonia levels, an effect of liver failure. 4. Decreased urinary output is not associated with liver failure, but with kidney failure. 5. Cholelithiasis is not caused by liver failure. Page Ref: 836 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

32 ..

33) The nurse is teaching a patient about the effects of liver failure. Which patient statement about manifestations indicates that teaching was effective? Select all that apply. 1. "My abdomen is becoming very large." 2. "My blood sugar is sometimes too high and sometimes too low." 3. "My left lower leg is red and swollen." 4. "My menstrual cycle has become very irregular." 5. "My skin appears yellow." Answer: 1, 2, 4, 5 Explanation: 1. Ascites occurs during liver failure due to low oncotic pressure related to a deficiency of serum albumin. 2. The liver's ability to use glycogen is impaired by liver failure, leading to difficulty controlling hypoglycemia and/or hyperglycemia. 3. The patient is describing symptoms of a blood clot. This is not associated with liver failure. Excessive bleeding is associated with liver failure. 4. Impaired metabolism of steroid hormones interferes with the menstrual cycle. 5. Impaired ability to metabolize and excrete bilirubin leads to a buildup of bilirubin in skin, causing a jaundiced appearance. Page Ref: 829 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

33 ..

34) The nurse is assessing a patient with liver failure and jaundice. Which question should the nurse ask to determine if the cause of the jaundice is hemolytic? 1. "Have you been diagnosed with a disorder of red blood cell destruction?" 2. "What color is your urine?" 3. "What color are your stools?" 4. "Do you have any gallbladder problems?" Answer: 1 Explanation: 1. Hemolytic jaundice develops when excess RBC destruction releases more bilirubin into circulation than the liver is able to process. 2. Darkened urine is more commonly associated with hepatic or obstructive jaundice. 3. Light or clay-colored stools are more commonly associated with hepatic or obstructive jaundice. 4. Patients with gallbladder disorders are also at risk for jaundice; however, this patient's liver failure is a given. Page Ref: 817 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

34 ..

35) The nurse teaches a patient about portal hypertension. Which patient statement indicates teaching was effective? 1. "In portal hypertension, blood backs up in the liver. It causes enlarged blood vessels in my esophagus." 2. "In portal hypertension, blood leaks from my liver. It causes me to feel hungry frequently." 3. "Portal hypertension means fast-spreading high blood pressure. It causes red veins on my arms." 4. "Portal hypertension means high blood pressure throughout my abdomen. It causes me to feel confused." Answer: 1 Explanation: 1. Portal hypertension, increased pressure in the portal system, has several effects when it is prolonged, including dilation of veins in the gastrointestinal tract and the abdominal wall. 2. Portal hypertension does not mean blood is leaking from the liver. Portal hypertension tends to suppress (not increase) the appetite. 3. Portal hypertension is not fast-spreading hypertension, and it is not defined as high blood pressure throughout the abdomen. In advanced liver failure, superficial varices may develop around the umbilicus (not on the arms), a feature known as caput medusae. 4. Portal systemic encephalopathy (or hepatic encephalopathy), impaired consciousness and mental status, results from the accumulation of toxic waste products in the blood (ammonia in particular) as blood bypasses the congested liver. This is not caused by high abdominal blood pressure. Page Ref: 818 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

35 ..

36) The patient in the icteric phase of hepatitis asks why stools are no longer brown. How should the nurse respond? 1. "Your liver isn't making any of the substance that makes stools brown." 2. "The pigment is backing up into your blood and turning your skin yellow." 3. "It is being released into your bloodstream and turning your blood darker red." 4. "The answer is not known. More research is needed regarding this question." Answer: 2 Explanation: 1. The liver continues to make bilirubin, even during hepatitis. 2. The icteric (jaundiced) phase usually begins 5 to 10 days after the onset of symptoms. It is heralded by jaundice of the sclera, skin, and mucous membranes. Inflammation of the liver and bile ducts prevents bilirubin from being excreted into the small intestine. As a result, the serum bilirubin levels are elevated, causing yellowing of the skin and mucous membranes. The stools are light brown or clay colored because bile pigment is not excreted through the normal fecal pathway. 3. The blood does not become darker when bilirubin levels are elevated. 4. The cause of this phenomenon is known. Page Ref: 819 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

36 ..

37) A patient who has three school-age children has jaundice and is diagnosed with hepatitis A after taking a trip to Central America. Which patient statement should the nurse address with the patient? 1. "I can't go home and expose my children to this." 2. "We cared for several very ill people on our trip." 3. "I plan to get a lot of rest in the next few days." 4. "I am likely to recover fully eventually." Answer: 1 Explanation: 1. Once jaundice develops, the amount of virus in the stool and the risk of spreading the disease decrease significantly. The nurse should teach that the patient was likely more contagious in the last 2 weeks than at the current time. 2. This disease is spread through the fecal-oral route. It is likely the patient contracted the illness on the trip. 3. Rest is recommended for the patient with hepatitis A. 4. Full recovery is the typical scenario with this illness. Page Ref: 819 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

37 ..

38) A patient with a distant history of injection substance use is diagnosed with hepatitis. For which type of hepatitis should the nurse plan care for this patient? 1. Hepatitis A 2. Hepatitis B 3. Hepatitis C 4. Hepatitis D Answer: 3 Explanation: 1. Hepatitis A usually resolves completely and rarely results in a carrier state. 2. Patients with hepatitis B are typically very ill following the preicteric phase, which is not consistent with this patient's history. 3. Hepatitis C is the primary worldwide cause of chronic hepatitis, cirrhosis, and liver cancer. It is transmitted through infected blood and body fluids. Injection drug use is the primary risk factor for HCV infection, accounting for nearly half of all new infections. Acute hepatitis C usually is asymptomatic; if symptoms do develop, they often are mild and nonspecific. The disease often is recognized long after exposure occurred, when secondary effects of the disease (such as chronic hepatitis or cirrhosis) develop. Few acute infections completely resolve; most progress to chronic active hepatitis. 4. Hepatitis D infects only people already infected with hepatitis B. Page Ref: 819-820 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

38 ..

39) The nurse is caring for a patient with hepatitis C who is treating the illness with licorice root. Which statement by the patient requires follow-up regarding this medication? 1. "I feel so tired all the time." 2. "My fingers feel numb and tingly." 3. "I have a dull ache in my abdomen." 4. "I have antibodies for hepatitis C in my blood." Answer: 2 Explanation: 1. Feeling tired is expected in a patient with hepatitis C. 2. Herbalists may use licorice root to treat hepatitis. It has both antiviral and anti-inflammatory effects. Long-term use of licorice root, however, can lead to hypertension and affect fluid and electrolyte balance. Reports of numbness and tingling in the fingers may be a sign of electrolyte imbalance. 3. A dull ache in the abdomen is often seen in patients with hepatitis. 4. It is expected that this patient would have antibodies to hepatitis C in the blood. Page Ref: 823 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

39 ..

40) The nurse is concerned that a patient with injuries from a motor vehicle crash is experiencing bleeding from liver trauma. What did the nurse assess to make this clinical determination? Select all that apply. 1. New onset of pruritus 2. New onset of lightheadedness 3. Heart rate 112 beats per minute 4. Requesting more water to drink 5. Respiratory rate 26 breaths per minute Answer: 2, 3, 4, 5 Explanation: 1. Pruritus is not a manifestation of bleeding. 2. Bleeding due to liver trauma may not be immediately apparent. A new onset of lightheadedness could indicate bleeding. 3. Bleeding due to liver trauma may not be immediately apparent. A rapid heart rate could indicate bleeding. 4. Bleeding due to liver trauma may not be immediately apparent. Thirst could indicate bleeding. 5. Bleeding due to liver trauma may not be immediately apparent. Shortness of breath could indicate bleeding. Page Ref: 839 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.2 Describe the pathophysiology and manifestations of liver disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gallbladder, liver, and pancreatic disorders.

40 ..

41) A patient with chronic pancreatitis is prescribed pancrelipase (Lipancreatin). What should the nurse instruct the patient about this medication? Select all that apply. 1. Take the medication with meals or snacks. 2. Take the medication with milk or ice cream. 3. Stop taking the medication if bowel movements increase. 4. Do not crush enteric coated doses of the medication. 5. Take this medication until advised otherwise by the healthcare provider. Answer: 1, 4, 5 Explanation: 1. Pancrelipase enhances the digestion of starches and fats in the gastrointestinal tract by supplying an exogenous source of the enzymes protease, amylase, and lipase. The drug promotes nutrition and decreases the number of bowel movements. This medication should be taken with meals or snacks. 2. This medication should not be taken with alkaline foods such as milk or ice cream. 3. This medication should be taken as directed by the healthcare provider. 4. Pancrelipase enhances the digestion of starches and fats in the gastrointestinal tract by supplying an exogenous source of the enzymes protease, amylase, and lipase. The drug promotes nutrition and decreases the number of bowel movements. Enteric coated doses of this medication should not be crushed. 5. Pancrelipase enhances the digestion of starches and fats in the gastrointestinal tract by supplying an exogenous source of the enzymes protease, amylase, and lipase. The drug promotes nutrition and decreases the number of bowel movements. This medication should be taken until advised otherwise by the healthcare provider. Page Ref: 844 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

41 ..

42) During a health assessment the nurse becomes concerned that a patient is at high risk for pancreatic cancer. What assessment finding caused this concern? Select all that apply. 1. The patient smokes cigarettes. 2. The patient has a body mass index of 32.5. 3. The patient has been treated for osteoarthritis. 4. The patient's uncle died from pancreatic cancer. 5. The patient has been diagnosed with chronic pancreatitis. Answer: 1, 2, 4, 5 Explanation: 1. Risk factors for pancreatic cancer include cigarette smoking. 2. Risk factors for pancreatic cancer include obesity. 3. Osteoarthritis is not a risk factor for pancreatic cancer. 4. Risk factors for pancreatic cancer include a genetic predisposition. 5. Risk factors for pancreatic cancer include chronic pancreatitis. Page Ref: 847 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gallbladder, liver, and pancreatic disorders.

42 ..

43) A patient recovering from Whipple's procedure is being transferred to the medical-surgical care area. On which intervention should the nurse focus to determine if the patient is developing a complication from the surgery? Select all that apply. 1. Assessing heart rate every 2 hours 2. Monitoring urine output every hour 3. Turning and repositioning every 2 hours 4. Measuring blood pressure every 2 hours 5. Assisting to a standing position every 4 hours Answer: 1, 2, 4 Explanation: 1. The major complications following Whipple's procedure are hemorrhage, bile leak, hypovolemic shock, and hepatorenal failure. Heart rate should be assessed every 2 hours. 2. The major complications following Whipple's procedure are hemorrhage, bile leak, hypovolemic shock, and hepatorenal failure. Urine output should be monitored. 3. Turning and repositioning will not help prevent complications from this procedure. 4. The major complications following Whipple's procedure are hemorrhage, bile leak, hypovolemic shock, and hepatorenal failure. Blood pressure should be assessed every 2 hours. 5. Assisting the patient to a standing position will not help prevent complications from this procedure. Page Ref: 847-848 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 25.3 Describe the pathophysiology and manifestations of exocrine pancreas disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gallbladder, liver, and pancreatic disorders.

43 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 26 Assessing the Renal System 1) A patient has urine that is cloudy and foul-smelling. Which diagnostic test should the nurse anticipate being prescribed for this patient? 1. Urine culture 2. Blood urea nitrogen (BUN) 3. Creatinine clearance 4. Residual urine Answer: 1 Explanation: 1. The patient's manifestations indicate a urinary tract infection. A urine culture is conducted to identify the causative organism of a UTI. 2. Blood urea nitrogen (BUN) measures the amount of urea (end product of protein metabolism) in the blood plasma. It does not identify infection. 3. Creatinine clearance is a 24-hour urine test used to identify renal function; it will not identify an infection. 4. Residual urine measures the amount of urine left in the bladder after voiding and does not identify an infection. Page Ref: 866 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

1 ..

2) When preparing a patient for an intravenous pyelogram (IVP), the nurse reviews diagnostic data. Which finding should the nurse report to the healthcare provider before sending the patient for the test? 1. Blood urea nitrogen (BUN) 55 mg/dL 2. Serum creatinine 1.3 mg/dL 3. Urine culture <10,000 organisms/mL 4. Residual urine of 80 mL Answer: 1 Explanation: 1. Blood urea nitrogen (BUN) of 55 mg/dL indicates that there might be a problem of renal function. Normal value is 5-25 mg/dL. The healthcare provider will need to be notified because an IVP involves the injection of dye that must eventually be cleared by the kidney; if there is already compromised renal function, the test may not be administered. 2. Serum creatinine 1.3 mg/dL is within the normal range, and does not need to be reported to the healthcare provider. 3. Urine culture <10,000 organisms/mL is within the normal range and does not need to be reported to the healthcare provider. 4. Residual urine of 80 mL is within the normal range and does not need to be reported to the healthcare provider. Page Ref: 863 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

2 ..

3) A patient recovering from surgery is prescribed a postvoiding residual urine test. What supplies should the nurse gather to complete this test? 1. A urine collecting device and a straight urinary catheter 2. A urine collecting device and a voiding diary 3. An indwelling urinary catheter and an insertion kit 4. A peripheral IV insertion kit and a urine collecting device Answer: 1 Explanation: 1. For a postvoiding residual urine test, the nurse needs a urine collection device and a straight catheter. 2. Voiding diaries are not required for this procedure. 3. Indwelling urinary catheters are not required for this procedure. 4. Peripheral IVs are not required for this procedure. Page Ref: 866 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

3 ..

4) An older patient is being evaluated for a renal health problem. Which serum creatinine level should the nurse expect for this patient? 1. 0.3 mg/dL 2. 2.4 mg/dL 3. 4.8 mg/dL 4. 6.4 mg/dL Answer: 1 Explanation: 1. Serum creatinine level reflects the by-product of muscle breakdown, and an older adult with less muscle mass can be expected to have a lower-than-normal level such as 0.3 mg/dL. The normal creatinine range for adults is 0.5-1.5 mg/dL. 2. A higher-than-normal level would not be expected for an older patient. 3. A higher-than-normal level would not be expected for an older patient. 4. A higher-than-normal level would not be expected for an older patient. Page Ref: 867 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.3 Differentiate considerations for assessing the renal systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

4 ..

5) The nurse is assessing a patient scheduled for a CT scan of the kidneys. Which finding should the nurse report to the primary healthcare provider? 1. Allergy to iodine and seafood 2. Urinary output of 1200 mL in 24 hours 3. Last bowel movement one day ago 4. Height 5'8" and weight 160 pounds Answer: 1 Explanation: 1. Allergy to iodine and seafood is correct because a CT scan of the kidneys requires the injection of a radiopaque dye that contains iodine. 2. Urinary output of 1200 mL in 24 hours is a normal finding, and therefore does not require that the physician be notified. 3. Last bowel movement one day ago is a normal finding, and therefore does not require that the physician be notified. 4. Height 5'8" and weight 160 lbs. are normal findings and do not require that the physician be notified. Page Ref: 864 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

5 ..

6) An older female patient is experiencing episodes of urinary incontinence. What should this indicate to the nurse? 1. An abnormal finding requiring further testing 2. The presence of a urinary infection 3. A normal outcome of the aging process 4. The result of having several children Answer: 1 Explanation: 1. Incontinence is not a normal finding and will require further investigation to identify the cause. 2. Episodes of urinary incontinence do not indicate the presence of a urinary infection. Although frequency and urgency can be symptoms of a urinary tract infection, a culture is necessary in order to determine infection. 3. Incontinence is not a normal outcome of the aging process. 4. While some stress incontinence may occur in multiparous women, incontinence is not normal and it is not necessarily the result of having had several children. Page Ref: 867 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.3 Differentiate considerations for assessing the renal systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

6 ..

7) A patient being treated for peritonitis from a ruptured appendix is concerned about developing a kidney infection. How should the nurse respond to this patient? 1. "Your kidneys are located outside the peritoneum, the sack that encloses the appendix." 2. "Good thinking. Infections in the abdomen can spread to other organs." 3. "You need to speak with your primary healthcare provider about your concern." 4. "We can check your urine daily to make sure the infection is not spreading." Answer: 1 Explanation: 1. The two kidneys are located outside the peritoneal cavity and on either side of the vertebral column at the levels of T12 through L3. 2. Although infections can spread, this is not the best choice as it does not address the patient's concern and may unduly alarm the patient. 3. There is no indication that the patient should speak with the primary healthcare provider at the current time. 4. There is no indication for daily urinalysis. Page Ref: 855 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

7 ..

8) A patient with an altered myogenic mechanism of the renal blood vessels asks why blood pressure control is important. How should the nurse respond to the patient? 1. "Your kidneys may have difficulty protecting themselves from high blood pressure." 2. "Your blood pressure medication is toxic to your kidneys in high doses." 3. "If not controlled, the condition will require an indwelling urinary catheter." 4. "High blood pressure increases your risk for kidney stones." Answer: 1 Explanation: 1. The myogenic mechanism, one factor in renal autoregulation, responds to pressure changes in the renal blood vessels, controlling the diameter of afferent arterioles. An increase in systemic blood pressure causes the renal vessels to constrict, whereas a decrease in blood pressure causes the afferent arterioles to dilate. These changes adjust the glomerular hydrostatic pressure and, indirectly, maintain the GFR. An alteration in this system exposes the kidneys to pressures that are too high for proper long-term kidney function. 2. This response does not address the patient's question. 3. Elevated blood pressure does not require an indwelling urinary catheter. 4. High blood pressure does not cause kidney stones. Page Ref: 857 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

8 ..

9) The nurse is reviewing the reabsorption of glucose and amino acids with a patient newly diagnosed with kidney disease. Which patient comment indicates that teaching has been effective? 1. "The nutrients move from blood to filtrate, then back to the blood." 2. "The nutrients move from filtrate to blood, then back to the filtrate." 3. "The nutrients remain in the kidneys at all times." 4. "The nutrients are large molecules and remain in the blood at all times." Answer: 1 Explanation: 1. Reabsorption may be active or passive. Substances move from the blood into the filtrate, then are reclaimed into the blood. 2. This statement indicates incorrect comprehension about kidney reabsorption. 3. This statement indicates incorrect comprehension about kidney reabsorption. 4. This statement indicates incorrect comprehension about kidney reabsorption. Page Ref: 858 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

9 ..

10) A patient who is a healthcare provider at another facility states the need to micturate. How should the nurse respond to this patient? 1. "There is a restroom at the end of the hallway." 2. "Have you been taking your medication on a daily basis?" 3. "Do you have a supply of sterile catheters?" 4. "Do you have someone who can drive you home?" Answer: 1 Explanation: 1. Micturition is the act of urinating or voiding. The best response is to direct the patient to a restroom. 2. Micturition has nothing to do with medication. 3. Micturition has nothing to do with the need for sterile catheters. 4. Micturition has nothing to do with the patient's ability to drive. Page Ref: 859 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

10 ..

11) The nurse is reviewing risk factors for bladder infections with a female patient. Which patient statement indicates that teaching has been effective? 1. The urinary meatus in females is closer to the bladder than in most males. 2. The urinary meatus in females is farther from the anus than most males. 3. The pH of the female urethra is more conducive to infection. 4. Females urinate more frequently than males, increasing risk. Answer: 1 Explanation: 1. In females, the urethra is approximately 1.5 inches (3 to 5 cm) long, and the urinary meatus is anterior to the vaginal orifice. 2. The female urinary meatus is closer, not farther, from the anus than in most males, also increasing risk for bladder infections. 3. The pH of the female urethra is not more conducive to infection. 4. Frequent urination decreases the risk of bladder infection. Page Ref: 859 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

11 ..

12) The parent of a child with a urinary tract infection is concerned that the child may develop a genetic kidney problem in the future. What information provided by the parent should the nurse use to determine the child's risk for a genetic kidney disorder? 1. "My mother had lots of cysts on her kidneys." 2. "I have a bladder infection at least once a year." 3. "The child's father has Parkinson disease." 4. "My father had kidney cancer." Answer: 1 Explanation: 1. When conducting a health assessment interview and physical assessment, it is important for the nurse to consider genetic influences on health. During the health assessment interview, ask about family members with health problems affecting kidney function, or of family members diagnosed with polycystic disease. A grandmother with polycystic kidney disease increases the grandchild's risk for having the disorder. 2. A yearly bladder infection in a mother is not the most important indicator of a genetic kidney disorder. 3. Parkinson disease is not associated with kidney disease. 4. Kidney cancer is not highly associated with heredity. Page Ref: 861 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

12 ..

13) The nurse suspects a patient is experiencing a distended bladder. Which patient statement did the nurse use to make this determination? 1. "I am in pain, and it is worse when I press on my abdomen." 2. "My back is killing me." 3. "It feels like someone is stabbing me in the abdomen with a knife." 4. "It hurts constantly with spasms once in a while." Answer: 1 Explanation: 1. The patient with a distended bladder experiences constant pain increased by any pressure over the bladder. 2. Kidney pain is experienced in the back and the costovertebral angle (the angle between the lower ribs and adjacent vertebrae) and may spread toward the umbilicus. 3. Renal colic (pain in response to renal calculi moving through the ureter) is severe, sharp, stabbing, and excruciating; often it is felt in the flank, bladder, urethra, testes, or ovaries. 4. Bladder and urethral pain is usually dull and continuous but may be experienced as spasms. Page Ref: 860 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

13 ..

14) A patient injured in the home and unable to receive help or healthcare for 48 hours has a blood urea nitrogen level of 50 mg/dL and serum creatinine level of 1.0 mg/dL. For which problem should the nurse plan care for first for this patient? 1. Dehydration 2. Anxiety 3. Pain 4. Poor nutrition Answer: 1 Explanation: 1. To assess whether the patient's elevated blood urea nitrogen is caused by dehydration or renal failure, the nurse assesses the serum creatinine value. The patient's serum creatinine is normal, which does not indicate kidney failure. This patient is dehydrated. 2. These laboratory values are not relevant to the problem of anxiety. 3. These laboratory values are not relevant to the problem of pain. 4. These laboratory values are not relevant to the problem of poor nutrition. Page Ref: 863 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

14 ..

15) The nurse is reviewing the serum creatinine laboratory results for a group of patients. Which patient should the nurse identify as being at risk for having falsely altered serum creatinine levels? Select all that apply. 1. Patient with rhinovirus taking 10,000 mg of vitamin C daily 2. Patient with Parkinson disease and a prescription for methyldopa 3. Patient with bipolar disorder and a prescription for lithium carbonate 4. Patient with acne vulgaris and a prescription for tetracycline 5. Patient with insomnia taking over-the-counter melatonin Answer: 1, 2, 3 Explanation: 1. Vitamin C (ascorbic acid) can affect the serum creatinine level. 2. Methyldopa can affect the serum creatinine level. 3. Lithium carbonate can affect the serum creatinine level. 4. Tetracycline is not an antibiotic identified as affecting the serum creatinine level. 5. Melatonin is not a supplement identified as affecting the serum creatinine level. Page Ref: 863 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

15 ..

16) The nurse is reviewing laboratory data for a patient who had a voiding cystogram that revealed an urge to void at 100 mL. For which potential problem should the nurse plan care for this patient? 1. Urinary incontinence 2. Alteration in integumentary status 3. Inability to provide self-care 4. Urinary retention Answer: 1 Explanation: 1. A patient who has a sensation of an urge to void at 100 mL is at risk for urinary incontinence. 2. A patient who has a sensation of an urge to void at 100 mL is not at risk for problems with the integumentary status. 3. A patient who has a sensation of an urge to void at 100 mL is not at risk for problems with self-care. 4. A patient who has a sensation of an urge to void at 100 mL is not at risk for problems with urinary retention. Page Ref: 864 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

16 ..

17) The nurse is teaching a patient about a voiding cystogram. Which patient statement indicates that teaching has been effective? Select all that apply. 1. "A urinary catheter will be placed in my bladder." 2. "My bladder will be filled with fluid." 3. "I will tell you when my bladder feels full." 4. "A peripheral IV will be inserted in my arm." 5. "I will be sedated for the procedure." Answer: 1, 2, 3 Explanation: 1. During this procedure, a urinary catheter will be placed in the bladder so that fluid can be instilled directly into the bladder. 2. During this procedure, the bladder will be filled. 3. During this procedure, when the bladder is being filled the patient will be asked to describe the first urge to void, and the sensation of being unable to delay urination any longer. 4. A peripheral IV is not needed for this procedure. 5. The patient is not sedated as the patient must report when the sensation of bladder filling is occurring. Page Ref: 864 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

17 ..

18) A patient is scheduled for a cystogram. What information in the patient's history should the nurse bring to the healthcare provider's attention as potentially causing a problem with the patient? Select all that apply. 1. Cystitis 2. Prostatitis 3. Hypersensitivity to anesthetics 4. Right-sided hemiplegia 5. Chronic pain Answer: 1, 2, 3 Explanation: 1. A history of cystitis could result in sepsis after the procedure. 2. A history of prostatitis could result in sepsis after the procedure. 3. A history of hypersensitivity to anesthetics could result in problems after the procedure. 4. Right-sided hemiplegia is not an issue for this patient. 5. Chronic pain is not an issue for this patient. Page Ref: 864 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

18 ..

19) The nurse is providing preoperative teaching for a patient recovering from a cystogram. For which reason should the patient be instructed to contact the healthcare provider? 1. Bloody urine 2. Thirst 3. Muscle cramps 4. Hunger Answer: 1 Explanation: 1. Some blood is expected in the urine following the procedure. The patient should be instructed to immediately notify the physician if the urine remains bloody for more than three voidings after the procedure, or if bright bleeding develops. 2. Thirst is not an adverse effect after a cystogram. 3. Muscle cramps are not an adverse effect after a cystogram. 4. Hunger is not an adverse effect after a cystogram. Page Ref: 864 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

19 ..

20) The nurse is providing discharge teaching to a patient recovering from a cystogram. What should the nurse include in this teaching? Select all that apply. 1. Take a sitz bath. 2. Increase oral fluid intake. 3. Take acetaminophen for minor pain. 4. Apply heat to the lower back. 5. Drink one ounce of brandy or rum with warm water. Answer: 1, 2 Explanation: 1. Appropriate techniques for relieving pain after a cystogram include taking a sitz bath. 2. Appropriate techniques for relieving pain after a cystogram include increasing oral fluid intake. 3. Appropriate techniques for relieving pain after a cystogram do not include the use of overthe-counter pain medication. 4. Apply heat to the lower abdomen, not the lower back. 5. Tell the patient to avoid alcoholic drinks for two days and that a slight burning sensation with voiding may occur for a day or two. Page Ref: 864 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

20 ..

21) The nurse is reviewing the laboratory results for a patient. Which information should the nurse identify as being used to determine the patient's estimated glomerular filtration rate? Select all that apply. 1. Serum creatinine 2. Patient's age 3. Patient's gender 4. Patient's racial origin 5. Serum blood urea nitrogen Answer: 1, 2, 3, 4 Explanation: 1. The EGFR is calculated based on the serum creatinine. 2. The EGFR is calculated based on the patient's age. 3. The EGFR is calculated based on the patient's gender. 4. In some instances, the EGFR is calculated based on racial origin. 5. Serum blood urea nitrogen is not utilized. Page Ref: 864 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

21 ..

22) The nurse is creating a teaching plan for a patient who is taking the oral hypoglycemic agent metformin (Glucophage). For which reason should the nurse instruct the patient to contact the healthcare provider? 1. Need a diagnostic test that uses iodinated contrast. 2. Urine becomes orange or red-tinted. 3. Urine becomes more concentrated. 4. Need an intermittent or indwelling urinary catheterization. Answer: 1 Explanation: 1. Oral hypoglycemic agents are contraindicated for use with iodinated contrast, as the combination of the two can precipitate renal failure. Patients should be taught to inform all healthcare providers if they have a prescription for an oral hypoglycemic agent. 2. Orange or red-tinted urine has no interaction with metformin. 3. Concentrated urine has no interaction with metformin. 4. Urinary catheterizations have no interaction with metformin. Page Ref: 864, 865 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

22 ..

23) A patient who has prescriptions for renal tests plans to have an intravenous pyelogram before a barium enema. Which response should the nurse make to the patient? 1. "Please make your appointments as you have indicated." 2. "Please clarify with your primary healthcare provider which should be completed first." 3. "Please reverse the order of your planned appointments." 4. "The order of the tests is irrelevant. You may change the order to meet your needs." Answer: 1 Explanation: 1. Schedule an IVP prior to any ordered barium test or gallbladder studies using contrast material, as residual contrast material from the barium enema or gallbladder studies may interfere with the IVP results. 2. The patient does not need to contact the healthcare provider to clarify the scheduling of the tests. 3. The IVP should be done before the barium enema. 4. The order of the tests is relevant. The IVP should be done before the barium enema. Page Ref: 865 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

23 ..

24) The nurse is reviewing teaching with a patient who is scheduled for an intravenous pyelogram. Which patient statement indicates that additional teaching is required? 1. "I will not drink any fluids for at least 12 hours before the procedure." 2. "I will start the bowel prep with a suppository the night before the procedure." 3. "I will take the prescribed laxative the morning of the procedure." 4. "I will not eat solid food for at least 8 hours before the procedure." Answer: 1 Explanation: 1. Clear liquids are allowed. 2. Instruct the patient to complete ordered pretest bowel preparation the night before the procedure. 3. Instruct the patient to complete ordered pretest bowel preparation the morning of the test. 4. Tell the patient not to eat food for 8 to 12 hours prior to the test. Page Ref: 865 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

24 ..

25) A patient is scheduled for an MRI of the kidneys. Which question should the nurse avoid when preparing the patient for this test? 1. "When did you last have anything to eat or drink?" 2. "Have you ever been treated for chest pain?" 3. "Do you have any tattoos?" 4. "Is there any possibility you could be pregnant?" Answer: 1 Explanation: 1. There are no restrictions regarding food or fluids for this test. 2. Patients with a history of chest pain should be asked if they have a prescription for transdermal nitroglycerin patches, which must be removed prior to the test. 3. The nurse should assess for any metallic implants (such as pacemakers, clips on brain aneurysms, body piercings, tattoos, and shrapnel). If present, the nurse should notify the imaging physician. 4. Ask if patient is pregnant; if so, the test is not performed. Page Ref: 865 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

25 ..

26) A patient has a portable ultrasonic bladder scan. Which finding should the nurse identify as being within normal limits? 1. Less than 100 mL of urine in the bladder. 2. Between 100 and 150 mL of urine in the bladder. 3. Between 150 and 200 mL of urine in the bladder. 4. More than 200 mL of urine in the bladder. Answer: 1 Explanation: 1. A normal ultrasonic bladder scan finding is less than 100 mL for a residual voiding. 2. A finding of between 100 and 150 mL would not be a normal outcome after a portable ultrasonic bladder scan. 3. A finding of between 150 and 200 mL would not be a normal outcome after a portable ultrasonic bladder scan. 4. A finding of more than 200 mL would not be a normal outcome after a portable ultrasonic bladder scan. Page Ref: 865 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

26 ..

27) A patient who is scheduled to have a renal angiogram asks why pulses are being checked in the feet. What should the nurse respond to this patient? 1. "I feel your pulses there. I can check that the blood is flowing properly to your legs and feet." 2. "Why do you ask?" 3. "It is a nursing thing." 4. "A needle is inserted in your femoral artery so the circulation to your extremity could be compromised during this test." Answer: 1 Explanation: 1. For this test, a contrast medium is injected into the femoral artery. Afterward, the integrity of the artery is assessed by checking peripheral pulses in the feet. 2. This response does not address the patient's question. 3. Telling the patient "it is a nursing thing" minimizes the patient's concern. 4. This response uses medical terminology that the patient might not understand. Page Ref: 865 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

27 ..

28) A patient is recovering from a renal biopsy. Which action should the nurse complete while caring for this patient? 1. Apply pressure to site for 15 minutes after procedure. 2. Instruct the patient to avoid eating for 8 to 12 hours. 3. Teach the patient to restrict oral fluid intake. 4. Direct the patient to expect to have decreased urination. Answer: 2 Explanation: 1. After the biopsy, if the percutaneous route was used, apply pressure to the site for about 20 min to prevent bleeding. 2. The patient needed to take nothing by mouth for 8 to 12 hours before the procedure, not after. 3. Oral fluid intake should be increased after the procedure. 4. The patient should be instructed to report changes in urine output to the healthcare provider. Page Ref: 866 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

28 ..

29) A patient with an allergy to iodine is scheduled to have diagnostic tests. For which test should the nurse notify the healthcare provider? 1. Renal angiogram 2. Renal scan 3. Voiding cystogram 4. Portable ultrasonic bladder scan Answer: 1 Explanation: 1. An angiogram includes the use of contrast dye, which often contains iodine. The nurse should contact the primary healthcare provider to report the iodine allergy. 2. A renal scan does not require the use of contrast media. 3. A voiding cystogram does not require the use of contrast media. 4. A portable ultrasonic bladder scan does not require the use of contrast media. Page Ref: 865 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

29 ..

30) A patient scheduled for a renal ultrasound asks if the procedure is going to be painful. What should the nurse do to help the patient prepare for this diagnostic test? 1. Describe the typical experience of a patient having a renal ultrasound. 2. Discuss feelings associated with painful experiences. 3. Explain pain medications available during this procedure. 4. Describe the typical experience of a patient using conscious sedation. Answer: 1 Explanation: 1. A renal ultrasound is a noninvasive test conducted to detect renal or perirenal masses, identify obstructions, and diagnose renal cysts and solid masses. It is done by applying a conductive gel to the skin and placing a small external ultrasound probe on the patient's skin. Sound waves are recorded on a computer as they are reflected off tissues. 2. There is no discomfort associated with the test. 3. Pain medications are not needed. 4. Conscious sedation is not needed for this test. Page Ref: 866 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

30 ..

31) During a home visit the nurse asks the patient for a specimen for a urinalysis. Which patient statement indicates that the nurse needs to provide additional teaching about the specimen? 1. "I will get the specimen the next time I void." 2. "I won't touch the inside of the cup or lid." 3. "I will refrigerate the specimen until it is picked up tomorrow." 4. "I will give the laboratory a list of the medications I am taking." Answer: 1 Explanation: 1. An early morning specimen is preferred. 2. The patient should not touch the inside of the cup or lid. 3. The specimen should be refrigerated. 4. The laboratory should know the patient's current medications. Page Ref: 866 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

31 ..

32) A patient is experiencing burning with urination and urgency. Which laboratory test result should the nurse monitor for this patient's manifestations? 1. Serum creatinine 2. Urine osmolality 3. BUN 4. Urine culture Answer: 4 Explanation: 1. Serum creatinine is used to evaluate kidney function. 2. Urine osmolality is used to evaluate fluid balance. 3. BUN is used to evaluate kidney function. 4. The patient is demonstrating signs of a urinary tract infection. A urine culture is conducted to identify the causative organism of a UTI. Page Ref: 866 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

32 ..

33) The nurse is reviewing the results of a patient's urinalysis. Which finding indicates that a pathological process might be occurring with this patient? 1. Appearance: cloudy 2. Odor: aromatic 3. pH: 5.2 4. Glucose: negative Answer: 1 Explanation: 1. Cloudy urine indicates bacteria, pus, RBCs, WBCs, phosphates, prostatic fluid spermatozoa, or urates. 2. Aromatic odor is a normal finding. 3. The pH of 5.2 is a normal finding. 4. Negative for glucose is a normal finding. Page Ref: 857 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

33 ..

34) The nurse is reviewing teaching materials prepared to obtain midstream clean catch urine for culture. Which information within this plan needs to be corrected by the nurse? 1. Male patients should retract the foreskin and cleanse the glans with three cotton sponges saturated with cleansing solution, using a circular motion. 2. Female patients should separate the labia with one hand and clean the labia with the other, using sterile cotton swabs saturated with a cleansing solution, wiping back to front. 3. After cleansing, patients should start voiding and then begin to collect the specimen. 4. Patients should start taking prescribed antibiotics only after the specimen is collected. Answer: 2 Explanation: 1. Male patients should retract the foreskin and cleanse the glans with three cotton sponges saturated with cleansing solution, using a circular motion. 2. The female patient should cleanse the perineum with a front-to-back motion to avoid contaminating the urethral meatus with fecal bacteria. 3. The patient should start voiding and collect the specimen after cleansing. 4. The patient should start voiding and collect the specimen after cleansing. Page Ref: 866 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

34 ..

35) The nurse instructs a patient about adult polycystic kidney disease (APKD). Which patient statement indicates that teaching has been effective? Select all that apply. 1. "This disorder can be cured if I take my medication carefully." 2. "APKD is inherited from parent to child." 3. "The problem that causes this disease is in the cell chromosomes." 4. "Many fluid-filled sacs are found in the kidneys." 5. "This disorder can cause my kidneys to work poorly." Answer: 2, 3, 4, 5 Explanation: 1. There is no medication that can cure adult polycystic kidney disease (APKD). It is characterized by a gradual loss of kidney tissue with resultant chronic kidney disease. 2. Adult polycystic kidney disease (APKD) is linked to a familial chromosome 16 disorder. 3. Adult polycystic kidney disease (APKD) is linked to a familial chromosome 16 disorder. 4. The disease is characterized by large cysts in one or both kidneys. 5. The disease is characterized by a gradual loss of kidney tissue with resultant chronic renal failure. Page Ref: 861 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

35 ..

36) During a health history the nurse learns that a newly married female patient has a family history of both type 1 and type 2 diabetes mellitus. Which type of referral should the nurse consider for this patient? 1. A genetic counselor 2. A home health nurse 3. An obstetrician 4. A physical therapist Answer: 1 Explanation: 1. When conducting a health assessment interview and physical assessment, it is important to consider genetic influences on adult health. During the health assessment interview, ask about family members with health problems affecting kidney function or those diagnosed with polycystic disease or diabetes mellitus. During the physical assessment, assess for manifestations that might indicate a genetic disorder. If data indicate the presence of genetic risk factors or alterations, ask about genetic testing and refer for appropriate genetic counseling and evaluation. 2. The patient does not need a home health nurse. 3. The patient does not need an obstetrician. 4. The patient does not need a physical therapist. Page Ref: 861 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

36 ..

37) An 80-year-old patient has decreased renal cortexes, atherosclerosis of the renal arteries, and hypo-osmolality of urine. What should the nurse consider first as an explanation for this patient's renal status? 1. These are typical changes associated with aging. 2. These are signs of chronic renal failure. 3. These are signs of acute renal failure. 4. These are signs of a genetic renal disorder. Answer: 1 Explanation: 1. Typical age-related changes of the renal system include a decreased size of the renal cortex, atherosclerosis of the renal arteries, and hypo-osmolality. 2. Because of the patient's age, this explanation might not be appropriate. 3. Because of the patient's age, this explanation might not be appropriate. 4. Because of the patient's age, this explanation might not be appropriate. Page Ref: 867 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.3 Differentiate considerations for assessing the renal systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

37 ..

38) The nurse completes an assessment of renal and urinary function with an older male patient. Which finding should the nurse report to the healthcare provider? 1. Urinary incontinence 2. Urinary frequency 3. Urinary urgency 4. Nocturia Answer: 1 Explanation: 1. Urinary incontinence is not a normal part of aging and requires immediate nursing intervention. 2. Urinary frequency is more common in older adults. This may represent normal changes expected with aging. 3. Urgency is more common in older adults. This may represent normal changes expected with aging. 4. Nocturia is more common in older adults. This may represent normal changes expected with aging. Page Ref: 867 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 26.3 Differentiate considerations for assessing the renal systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

38 ..

39) A patient is prescribed diagnostic tests to determine renal functioning. What test should the nurse review to determine the patient's glomerular filtration rate (GFR)? 1. Creatinine clearance 2. Blood urea nitrogen (BUN) 3. Intravenous pyelogram (IVP) 4. Renal ultrasound Answer: 1 Explanation: 1. Creatinine clearance measures the ability of the kidney to clear a given amount of creatinine out of the plasma within a given time period. Creatinine is a substance produced from the breakdown of muscle and is cleared by the kidney at a constant rate. This test is used to determine the glomerular filtration rate or the ability of the kidney to clear substances out of the plasma. 2. Blood urea nitrogen (BUN) measures the amount of urea in the plasma, and although it is reflective of kidney function, it can be affected by both protein intake and fluid balance. 3. Intravenous pyelogram (IVP) identifies the structures of the urinary system, not the function. 4. Renal ultrasound identifies renal or perirenal masses or obstructions. Page Ref: 864 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the renal system.

39 ..

40) A patient is concerned because the urine has changed to red-brown in color since starting a new medication. Which medication should the nurse suspect is causing this patient's change in urine color? 1. Phenytoin (Dilantin) 2. Amitriptyline (Elavil) 3. Injectable iron 4. Phenazopyridine (Pyridium) Answer: 1 Explanation: 1. Red-brown urine can occur when taking phenytoin (Dilantin). 2. Amitriptyline (Elavil) can cause the urine to turn green or blue. 3. Injectable iron can cause the urine to turn brown or black. 4. Phenazopyridine (Pyridium) can cause the urine to turn orange. Page Ref: 857 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

40 ..

41) The nurse is preparing to indirectly percuss a patient's kidneys. In which order should the nurse perform this assessment? Place in order the steps of the process. Choice 1. Stand behind the patient. Choice 2. Curl the dominant hand into a fist. Choice 3. Assist the patient to a sitting position. Choice 4. Place nondominant hand over the costovertebral angle. Choice 5. Strike the back of the nondominant hand with the dominant hand. Answer: 3, 1, 2, 4, 5 Explanation: Choice 1. The nurse should stand behind the patient after assisting to a sitting position. Choice 2. The nurse should curl the dominant hand into a fist after standing behind the seated patient. Choice 3. The nurse should first assist the patient to a sitting position. Choice 4. The nurse should place the nondominant hand over the patient's costovertebral angle after curling the patient's dominant hand into a fist. Choice 5. The nurse should strike the back of the nondominant hand with the dominant hand that is curled into a fist. Page Ref: 861 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

41 ..

42) While conducting a physical assessment, the nurse suspects that a male patient has a urinary tract or sexually transmitted infection. What did the nurse assess to make this clinical decision? Select all that apply. 1. Redness of the urinary meatus 2. Swelling from the urinary meatus 3. Discharge from the urinary meatus 4. Urinary meatus on the dorsal surface 5. Urinary meatus on the ventral surface Answer: 1, 2, 3 Explanation: 1. Increased redness of the urinary meatus may indicate UTI or sexually transmitted infection. 2. Swelling of the urinary meatus may indicate UTI or sexually transmitted infection. 3. Discharge from the urinary meatus may indicate UTI or sexually transmitted infection. 4. Urinary meatus on the dorsal surface of the penis indicates epispadias. 5. Urinary meatus on the ventral surface of the penis indicates hypospadias. Page Ref: 862 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

42 ..

43) While reviewing the results of a patient's urinalysis, the nurse suspects that a patient has kidney disease. Which finding caused the nurse to come to this conclusion? Select all that apply. 1. pH 6.2 2. +3 ketones 3. Colorless urine 4. Protein 7 mg/dL 5. Specific gravity 1.001 Answer: 3, 4, 5 Explanation: 1. A pH of 6.2 is within normal limits. 2. Ketones in the urine indicates starvation or a high protein diet. 3. Colorless urine indicates very dilute urine as seen in kidney disease. 4. Protein > 5mg/dL occurs in kidney disease. 5. Specific gravity <1.005 occurs in kidney disease. Page Ref: 857 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.1 Describe the anatomy, physiology, and functions of the kidneys and urinary tract, and identify abnormal findings that may indicate impairments of the renal system. MNL Learning Outcome: 3. Interpret abnormal findings of the renal system collected during assessment.

43 ..

44) During a health history the nurse is concerned that a male patient is at risk for developing bladder cancer. Which information from the history caused the nurse to have this concern? Select all that apply. 1. Plays tennis twice a week 2. Smokes 1 ppd of cigarettes 3. Sleeps 7 to 8 hours each night 4. Eats a salad several times a week 5. Works in a steel manufacturing plant Answer: 2, 5 Explanation: 1. Physical activity is a not a risk factor for bladder cancer. 2. Smoking is a risk factor for bladder cancer. 3. Amount of sleep is not a risk factor for bladder cancer. 4. There are no identified foods that increase the risk for bladder cancer. 5. Exposure to industrial chemicals is a risk factor for bladder cancer. Page Ref: 861 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

44 ..

45) A male patient is admitted for renal colic. When conducting this patient's physical assessment, on which area should the nurse focus to determine the type and amount of pain? Select all that apply. 1. Flank 2. Testes 3. Urethra 4. Bladder 5. Umbilicus Answer: 1, 2, 3, 4 Explanation: 1. Renal colic is pain associated with renal calculi moving through the ureter. This pain is severe, sharp, stabbing, and excruciating and is often felt in the flank. 2. Renal colic is pain associated with renal calculi moving through the ureter. This pain is severe, sharp, stabbing, and excruciating and is often felt in the testes. 3. Renal colic is pain associated with renal calculi moving through the ureter. This pain is severe, sharp, stabbing, and excruciating and is often felt in the urethra. 4. Renal colic is pain associated with renal calculi moving through the ureter. This pain is severe, sharp, stabbing, and excruciating and is often felt in the bladder. 5. Umbilical pain is associated with kidney disease. Page Ref: 860 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 26.2 Outline the components of the assessment of the renal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the renal system.

45 ..

46) The nurse is preparing a teaching tool on bladder health for a community fair. Which disease process should the nurse identify as the focus of bladder health promotion? Select all that apply. 1. Kidney stones 2. Bladder cancer 3. Prostate cancer 4. Urinary incontinence 5. Urinary tract infections (UTIs) Answer: 2, 4, 5 Explanation: 1. Bladder health promotion does not focus on the prevention of kidney stones. 2. Bladder health promotion focuses on the prevention of bladder cancer. 3. Bladder health promotion does not focus on the prevention of prostate cancer 4. Bladder health promotion focuses on the prevention of urinary incontinence. 5. Bladder health promotion focuses on the prevention of urinary tract infections (UTIs). Page Ref: 868 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 26.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

46 ..

47) A patient has a history of urinary tract infections (UTIs). What should the nurse instruct this patient to help maintain acid urine? Select all that apply. 1. Reduce the intake of water. 2. Avoid drinking fruit juices. 3. Take vitamin C supplements. 4. Avoid excess milk consumption. 5. Drink two glasses of low sugar cranberry juice each day. Answer: 2, 3, 4, 5 Explanation: 1. Water should be consumed to keep the urinary system flushed of microorganisms and toxic waste products. 2. Suggesting measures to maintain acid urine include avoid drinking fruit juices. 3. Suggesting measures to maintain acid urine include taking vitamin C supplements. 4. Suggesting measures to maintain acid urine include avoiding excess milk consumption. 5. Suggesting measures to maintain acid urine include drinking two glasses of low sugar cranberry juice each day. Page Ref: 868 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 26.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the renal system collected during assessment and health promotion activities to support the health of this body system.

47 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 27 Nursing Care of Patients with Urinary Tract Disorders 1) A female patient has a history of repeated urinary tract infections (UTIs). What should the nurse include in the assessment of this patient? 1. Preferred method of birth control 2. Employment status 3. Height and weight 4. Activity status Answer: 1 Explanation: 1. Risk factors for UTIs include sexual intercourse and the use of diaphragm and spermicidal compounds for birth control. 2. Employment status does not have a direct relationship to repeat UTIs. 3. Height and weight do not have a direct relationship to repeat UTIs. 4. Activity status does not have a direct relationship to repeat UTIs. Page Ref: 872 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

1 ..

2) The nurse is caring for an older patient who is prone to developing urinary tract infections (UTIs). Which method of bladder emptying should be recommended for this patient? 1. Intermittent catheterization 2. Indwelling urinary catheterizations 3. Credé method 4. Timed intervals for taking patient to bathroom to void Answer: 1 Explanation: 1. Intermittent catheterization carries a lower risk of infection and is preferred for patients who are unable to empty the bladder by voiding. 2. An indwelling urinary catheter has a higher risk of infection. 3. The Credé method is a technique used to assist patients with spinal cord injury to empty the bladder. 4. Timed intervals for voiding would not be effective if the patient is unable to empty the bladder by voluntary voiding. The urine would remain in the bladder and be a site for infection to develop. Page Ref: 874 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

2 ..

3) A patient is diagnosed with chronic pyelonephritis. Which health problem is this patient at risk for developing? 1. Chronic kidney disease 2. Cystitis 3. Acute renal failure 4. Renal calculi Answer: 1 Explanation: 1. Chronic pyelonephritis involves chronic inflammation and scarring of the tubules and interstitial tissues of the kidney. It is a common cause of chronic kidney disease. 2. Cystitis may cause acute pyelonephritis. 3. Cystitis may cause acute renal failure. 4. Renal calculi are generally caused by dietary intake, not by chronic pyelonephritis. Page Ref: 874 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

3 ..

4) A patient with an indwelling urinary catheter is exhibiting signs of asymptomatic bacteriuria. What would be the best course of action for this patient? 1. Removing the catheter and beginning antibiotic therapy 2. Beginning intravenous antibiotic therapy 3. Beginning 3-day course of oral antibiotic therapy 4. Removing the catheter and monitoring for continued signs of bacteriuria Answer: 1 Explanation: 1. The preferred treatment for catheter-associated urinary tract infections (UTIs) is to remove the indwelling catheter, then administer a 7- to 14-day course of oral antibiotic therapy to eliminate the infection. 2. The catheter needs to be removed before antibiotic therapy is begun. 3. Antibiotics for this health problem should be prescribed for 7 to 14 days. 4. Removing the catheter without initiating antibiotic therapy would not solve the problem. The infection could worsen. Page Ref: 873-874 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

4 ..

5) A female patient asks the nurse for ways to prevent recurrent urinary tract infections. How should the nurse respond? 1. "Avoid douching." 2. "Clean the perineal area from back to front." 3. "Use feminine hygiene sprays." 4. "Wear clean nylon underpants." Answer: 1 Explanation: 1. The nurse should suggest measures to maintain the integrity of perineal tissues, including avoiding douching. 2. Women should be instructed to cleanse the perineal area from front to back after voiding and defecating. 3. Feminine hygiene sprays should be avoided. 4. Cotton briefs should be worn. Page Ref: 879 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

5 ..

6) A male patient comes to the emergency department with symptoms of renal colic. Which body structure should the nurse realize is obstructed by a calculus? 1. Ureter 2. Bladder 3. Renal pelvis 4. Urethra Answer: 1 Explanation: 1. Renal colic is acute, severe flank pain on the affected side. It develops when a stone obstructs the ureter and causes ureteral spasm. 2. Calculi in the bladder would not cause flank pain or colic. 3. Calculi in the renal pelvis would not cause flank pain or colic. 4. Calculi in the urethra would not cause flank pain or colic. Page Ref: 882 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.2 Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

6 ..

7) A male patient has a history of calcium calculi. Which medication should the nurse expect to be prescribed for this patient? 1. Metolazone (Zaroxolyn) 2. Penicillin (Pentids) 3. Allopurinol (Alloprim) 4. NSAIDs Answer: 1 Explanation: 1. A thiazide diuretic, which is frequently prescribed for calcium calculi, acts to reduce urinary calcium excretion and is very effective in preventing further stones. Metolazone (Zaroxolyn) is a thiazide diuretic. 2. Penicillin (Pentids) is an antimicrobial and does not affect the development of calcium stones. 3. Allopurinol (Alloprim) is used to reduce serum levels of uric acid and has no effect on the development of calcium stones. 4. NSAIDs (nonsteroidal anti-inflammatory drugs) are used to reduce pain and fever and have no effect on the development of calcium stones. Page Ref: 881 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2 Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

7 ..

8) A male patient is admitted for removal of a bladder papilloma. What should the nurse assess in this patient? 1. History of cigarette smoking 2. Daily fluid intake 3. Pedal pulses 4. Appetite level Answer: 1 Explanation: 1. Carcinogenic breakdown products of certain chemicals and from cigarette smoke are excreted in the urine and stored in the bladder, which possibly causes a local influence on abnormal cell development. Cigarette smoking is the primary risk factor for bladder cancer. The risk in smokers is twice that of nonsmokers. 2. Daily fluid intake is an important assessment but is not related to an increased risk for bladder papilloma. 3. Pedal pulses are an important assessment but are not related to an increased risk for bladder papilloma. 4. Appetite is an important assessment but is not related to an increased risk for bladder papilloma. Page Ref: 886 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

8 ..

9) A patient is discharged after transurethral resection of a superficial bladder tumor. What should the nurse include in this patient's discharge instructions? Select all that apply. 1. Avoid constipation and continue to use stool softener. 2. Increase fluid intake. 3. Maintain bed rest. 4. Call the physician if painless hematuria develops. 5. Make a follow-up appointment in 1 year. Answer: 1, 2, 4 Explanation: 1. The patient should be instructed to avoid straining with stool and take a stool softener. 2. The patient should be instructed to increase fluids to 2500-3000 mL/day. 3. Bed rest is not necessary after this surgery. 4. The patient should be instructed to monitor for excessive bleeding. 5. Follow-up appointments will be scheduled more frequently than every year. Page Ref: 888 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

9 ..

10) A patient has had a renal stent removed. What should be included in the care of this patient? 1. Monitoring urine output 2. Encouraging ambulation 3. Ensuring adequate protein intake 4. Monitoring blood pressure Answer: 1 Explanation: 1. Urine output should be monitored closely for the first 24 hours after stent removal. Edema or stricture of ureters may impede output and lead to hydronephrosis and kidney damage. 2. Ambulation is not a priority for this patient. 3. Adequate protein intake is not a priority for this patient. 4. Blood pressure monitoring is not a priority for this patient. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

10 ..

11) A male patient with a urinary stoma says, "I looked at it while you were out of the room. It's not so bad." Which behavior should the nurse consider this patient is demonstrating? 1. Coping 2. Denial 3. Grief 4. Anger Answer: 1 Explanation: 1. Adaptive mechanisms include learning as much as possible about the surgery and its effects, practicing procedures, setting realistic goals, and rehearsing various alternative outcomes. Accepting the stoma as part of the self is vital to adapting to the changed body image and is indicated by a willingness to perform self-care. 2. The patient may initially use defensive coping mechanisms such as denial, minimization, and dissociation from the immediate situation to reduce anxiety and maintain psychological integrity. 3. Grief may be expressed by the patient with a new stoma, but this patient's statement does not indicate grief. 4. Anger may be expressed by the patient with a new stoma, but this patient's statement does not indicate anger. Page Ref: 891 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with urinary tract disorders.

11 ..

12) A middle-aged male patient comes to the clinic complaining of "frequency" and voiding "small amounts of urine at a time." Which health problem should the nurse suspect is occurring with this patient? 1. Benign prostatic hypertrophy (BPH) 2. Cystitis 3. Renal calculi 4. Bladder cancer Answer: 1 Explanation: 1. Benign prostatic hypertrophy (BPH) is a common cause of urinary retention; difficulty initiating and maintaining urine flow is often the presenting complaint in men with BPH. 2. Cystitis symptoms may include frequency but would be coupled with burning, pain during urination, and hematuria. 3. Renal calculi would likely cause flank pain. 4. Bladder cancer symptoms would include hematuria. Page Ref: 893 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

12 ..

13) A female patient is admitted with an overdistended bladder. Which diagnostic test can be done to confirm the diagnosis of urine retention? 1. Bladder scan 2. Renal scan 3. Intravenous pyelography (IVP) 4. MRI Answer: 1 Explanation: 1. Urinary retention is confirmed using a bladder scan. 2. A renal scan provides information about the structure of the kidney and vascular flow in the renal system, but it is not the test of choice in determining urine retention. 3. Intravenous pyelography (IVP) provides information about the structure of the kidney and vascular flow in the renal system, but it is not the test of choice in determining urine retention. 4. An MRI would provide information about the structure of the kidney and vascular flow in the renal system, but it is not the test of choice in determining urine retention. Page Ref: 893 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

13 ..

14) While being catheterized for urinary retention, a patient becomes diaphoretic and pale. What should the nurse do to help this patient? 1. The nurse should clamp the catheter after draining 500 mL of urine. 2. No action is needed, as this situation is transient. 3. The nurse should remove the urinary catheter. 4. The nurse should provide the patient with fluids. Answer: 1 Explanation: 1. Some patients may experience a vasovagal response and become pale, sweaty, and hypotensive if the bladder is rapidly drained. The nurse should be aware that it is a possible response in some patients and be able to recognize and respond to it. Draining 500 mL increments and clamping the catheter for 5 to 10 minutes between increments may prevent this response. 2. The vasovagal response is a possible response in some patients during catheterization. The nurse should be able to recognize the vasovagal response and take the appropriate action. 3. Removing the urinary catheter will not address the symptoms. 4. Replacing fluids will not address the symptoms. Page Ref: 894 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

14 ..

15) An older patient with diabetes is diagnosed with a flaccid bladder. What should be included in the care of this patient? 1. Instruction on the Credé method of bladder emptying 2. The importance of maintaining alkaline urine 3. Instruction on the use of anticholinergic medications 4. Reminder to restrict fluids Answer: 1 Explanation: 1. The Credé method (applying pressure to the suprapubic region with the fingers of one or both hands), manual pressure on the abdomen, and the Valsalva maneuver (bearing down while holding one's breath) promote bladder emptying for the patient with a spastic or flaccid bladder. 2. Altering the pH of the urine would not help the patient adapt to the neurogenic issue that is causing flaccid bladder. 3. Taking anticholinergics would not help the patient adapt to the neurogenic issue that is causing flaccid bladder. 4. Restricting fluids would not help the patient adapt to the neurogenic issue that is causing flaccid bladder. Page Ref: 896 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

15 ..

16) A female patient with multiple medical problems experiences incontinence, regardless of the position or situation. For which type of incontinence should the nurse plan care? 1. Total 2. Urge 3. Stress 4. Overflow Answer: 1 Explanation: 1. Total incontinence is the loss of all voluntary control over urination, and urine loss occurs without stimulus and in all positions. 2. Urge incontinence is associated with a strong urge to void. 3. Stress incontinence is the result of coughing or laughing. 4. Overflow incontinence results from an inability to empty the bladder and is characterized by overdistention and the loss of small amounts of urine. Page Ref: 897 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

16 ..

17) An 80-year-old female patient says to the nurse, "I can't hold my water very well so I don't leave the house much." What is an appropriate nursing response? 1. "This is not something you have to live with. Talk with your doctor about this problem." 2. "I understand." 3. "I guess it's hard getting older." 4. "Do you get enjoyment out of watching television?" Answer: 1 Explanation: 1. Although urinary incontinence rarely causes serious physical effects, it frequently has significant psychosocial effects and can lead to lowered self-esteem, social isolation, and even institutionalization. Patients should be informed that urinary incontinence is not a normal consequence of aging and that treatments are available. 2. The nurse must give a response that addresses the problem while showing empathy. 3. The nurse must give a response that addresses the problem while showing empathy. 4. Asking the patient about television viewing has no relevance. Page Ref: 897 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

17 ..

18) A patient who is recovering from spinal surgery had "an accident" while attempting to reach the bathroom to void. Which type of incontinence did this patient probably experience? 1. Functional 2. Urge 3. Stress 4. Total Answer: 1 Explanation: 1. Functional incontinence results from physical, environmental, or psychosocial causes. Impaired mobility is one such cause. 2. Urge incontinence occurs when the patient must void immediately when the urge is perceived. 3. Stress incontinence is the result of coughing or laughing. 4. Total incontinence is the loss of all voluntary control over urination and urine loss occurring without stimulus and in all positions. Page Ref: 897 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

18 ..

19) A patient is scheduled for a lithotripsy for renal calculi. What should the nurse explain to the patient as the purpose of a bowel preparation prior to this procedure? 1. Ensuring maximum visualization of the kidney and the stones 2. Ensuring that there is no evidence of constipation prior to the procedure 3. Increasing comfort 4. Reducing postoperative pain Answer: 1 Explanation: 1. Fecal material in the bowel may impede fluoroscopic visualization of the kidney and stone. 2. Constipation prior to the procedure has no bearing on the procedure if bowel preparation is completed. 3. Bowel preparation would not contribute to patient comfort. 4. Bowel preparation would not reduce postoperative pain. Page Ref: 884 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.2 Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

19 ..

20) A patient is participating in bladder retraining activities. Which toileting activity will reduce the patient's episodes of incontinence? Select all that apply. 1. Scheduled toileting 2. Habit training 3. Intermittent straight catheterization 4. External catheter placement at bedtime 5. Use of adult incontinence protection devices Answer: 1, 2 Explanation: 1. Behavioral techniques such as scheduled toileting reduce the frequency of incontinence. Scheduled toileting is toileting at regular intervals (e.g., every 2 to 4 hours). 2. Habit retraining is toileting the patient on a schedule that corresponds with the normal pattern. 3. Intermittent straight catheterization is not a toileting activity. 4. External catheter placement is not a toileting activity. 5. Adult incontinence devices do not reduce periods of incontinence. Page Ref: 900 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

20 ..

21) A patient is being instructed on how to perform Kegel exercises. What should be included in these instructions? Select all that apply. 1. While voiding, stop the flow of urine and hold for a few minutes. 2. Tighten the muscles around the anus to resist defecation. 3. Take a deep breath and hold while performing the exercise. 4. Perform these exercises at least once per day. 5. Perform these exercises for at least several months. Answer: 1, 2 Explanation: 1. The patient begins Kegel exercises by identifying the pelvic muscles by stopping the flow of urine during voiding and holding for a few seconds. 2. The patient begins Kegel exercises by identifying the pelvic muscles by tightening the muscles around the anus as though resisting defecation. 3. The patient should keep abdominal muscles and breathing relaxed while performing Kegel exercises. 4. The exercises should be performed twice a day, 25 repetitions each time. 5. It is important to establish a routine because these exercises should be continued for life. Page Ref: 898 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

21 ..

22) A patient with a urinary diversion device is at risk for impaired skin integrity. Which intervention should the nurse perform for this patient? 1. Emptying the bag reservoir every 2 hours 2. Changing urine collection device every other day 3. Teaching self-catheterization technique 4. Monitoring for foul-smelling urine Answer: 1 Explanation: 1. Overfilling the collection bag can damage the seal, allowing leakage and contact of urine with the skin. 2. The urine collection device is changed as needed. 3. Teaching self-catheterization technique is not an appropriate intervention for this problem. 4. Monitoring for foul-smelling urine does not help with the risk for impaired skin integrity. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

22 ..

23) An older female patient asks why she is having more urinary tract infections (UTIs) now that she is older. What should the nurse explain is a contributing factor to the incidence of UTIs among older adult females? 1. Loss of tissue elasticity 2. Enhanced immune response 3. Reduced risk of urinary stasis 4. Reduced and less protective prostatic secretions Answer: 1 Explanation: 1. The loss of tissue elasticity results in changes in bladder position, which contributes to the development of UTIs. 2. An impaired immune response contributes to the increased incidence of UTIs in older females. 3. An increased risk of urinary stasis contributes to the higher incidence of UTIs in older females. 4. Prostatic secretions are found in males. Page Ref: 872-873 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

23 ..

24) A patient diagnosed with a symptomatic urinary tract infection (UTI) is prescribed phenazopyridine (Pyridium). What should the nurse instruct the patient about the color of the urine? 1. It will become orange or red. 2. It will have a green tint. 3. It will turn brown. 4. It will become clearer and pale yellow. Answer: 1 Explanation: 1. Phenazopyridine (Pyridium) turns urine orange or red. 2. This medication does not turn the color of urine to green. 3. This medication does not turn the color of urine to brown. 4. This medication does not turn the color of urine to a clear pale yellow. Page Ref: 876 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

24 ..

25) The nurse is preparing to collect a urine culture specimen from a catheterized patient. What should the nurse do to safely obtain this specimen? 1. With a sterile syringe, aspirate several milliliters of urine from the sampling port using sterile technique. 2. Disconnect the catheter from the drainage tubing and allow 1-3 mL of urine to drain into a sterile specimen container. 3. With a sterile syringe and needle, aspirate 50 mL of urine from the catheter above where it is connected to the drainage tubing. 4. Empty a small volume of urine from the urine collection bag into a sterile specimen cup. Answer: 1 Explanation: 1. Several milliliters of urine can be aspirated with a sterile syringe from the sampling port using sterile technique. 2. The urinary catheter and drainage system should remain a closed system to prevent infection. 3. The urinary catheter and drainage system should remain a closed system to prevent infection. 4. Urine in the drainage bag has collected over several hours and is not fresh, as needed for a culture specimen. Page Ref: 874 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

25 ..

26) The nurse instructs a female patient on ways to prevent urinary tract infections (UTIs). Which patient statement indicates that teaching has been effective? 1. "I should drink 2 to 2-1/2 quarts of fluid per day." 2. "I should limit my intake of water so I won't need to urinate so often." 3. "I should wear only nylon underpants." 4. "I should void every 6 hours while I am awake." Answer: 1 Explanation: 1. An intake of 2 to 2-1/2 quarts of fluid per day will help to prevent UTIs. 2. Fluid intake should be increased. 3. Cotton underpants are best, and nylon should be avoided because synthetic fibers dry and irritate the perineal area and promote bacteria growth. 4. The patient should not delay emptying the bladder when the urge is felt. Emptying the bladder every 2-4 hours is recommended to prevent urinary stasis. Page Ref: 877 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

26 ..

27) The nurse is instructing a patient with uric acid stones on methods to prevent lithiasis. Which patient statement indicates that teaching has been effective? 1. "I should avoid organ meats and sardines in my diet." 2. "I will increase purine-rich foods in my diet." 3. "I know to avoid eating vitamin D-enriched foods." 4. "I will have to make my urine more acidic by eating cheese, cranberries, grapes, and tomatoes." Answer: 1 Explanation: 1. The patient with uric acid stones requires a diet low in purines, which are found in organ meats and sardines. 2. The patient with uric acid stones requires a diet low in purines. 3. Patients with calcium stones should limit vitamin D. 4. A patient with uric acid stones should not try to make the urine more acidic. Page Ref: 881 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 27.2 Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

27 ..

28) The nurse observes a distended bladder and no change in urine output in a patient with an indwelling urinary catheter and drainage system. What should the nurse do first? 1. Assess the catheter tubing for kinks and position it so drainage is maintained by gravity. 2. Notify the physician. 3. Flush the catheter with sterile saline using a large syringe. 4. Change the catheter. Answer: 1 Explanation: 1. The nurse should assess and maintain the patency and integrity of all catheter systems. A kinked catheter may damage the urinary system. 2. Notifying the physician is not an immediate intervention. 3. Flushing a catheter increases the risk of infection. 4. Changing a catheter increases the risk of infection. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

28 ..

29) A patient with pyelonephritis asks the nurse to explain the condition. How should the nurse respond? 1. "It is an infection of the kidney." 2. "It is an inflammation of the bladder." 3. "It is an infection of the lower urinary tract." 4. "It is a blockage in the tube from your kidney to your bladder." Answer: 1 Explanation: 1. Pyelonephritis is an infection of the renal pelvis and parenchyma, the functional unit of the kidney. 2. Pyelonephritis is not an inflammation of the bladder. 3. Pyelonephritis does not occur in the lower urinary tract. 4. Pyelonephritis does not occur in the ureter. Page Ref: 874 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with urinary tract disorders.

29 ..

30) A patient is diagnosed with struvite kidney stones. What interventions should the nurse anticipate being prescribed for this patient? 1. Surgical intervention and antibiotic therapy 2. Limiting foods high in calcium and taking thiazide diuretics 3. Sodium-restricted diet and taking penicillamine 4. Low-purine diet and taking potassium citrate Answer: 1 Explanation: 1. Management of the patient with struvite kidney stones includes surgical intervention or lithotripsy to remove the stone and antibiotic therapy for urinary tract infections (UTIs). 2. Limiting foods high in calcium and prescribing thiazide diuretics is common management for the patient with calcium phosphate and/or oxalate kidney stones. 3. Sodium restriction and penicillamine therapy are part of the treatment for cystine stones. 4. A low-purine diet and potassium citrate are prescribed commonly for uric acid stones. Page Ref: 881 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2 Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

30 ..

31) A patient is experiencing postoperative urinary retention. Which medication should the nurse expect to be prescribed for this patient? 1. Bethanechol chloride (Urecholine) 2. Tolterodine (Detrol) 3. Propantheline bromide (Pro-Banthine) 4. Nitrofurantoin (Macrobid) Answer: 1 Explanation: 1. Bethanechol chloride (Urecholine) increases detrusor muscle tone, producing a contraction strong enough to initiate micturition. It is primarily used to treat postoperative and postpartum urinary retention. 2. Tolterodine (Detrol) is used to treat spastic bladder. 3. Propantheline bromide (Pro-Banthine) is used to treat spastic bladder. 4. Nitrofurantoin (Macrobid) is a urinary anti-infective medication. Page Ref: 895 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

31 ..

32) The nurse is caring for a patient with a urinary stoma. In which order should the nurse provide care? Place in order the steps of the process. Choice 1. Cleanse the skin around stoma with soap and water, rinse, and pat or air-dry. Choice 2. Assess the stoma, noting color and moisture. Choice 3. Remove the old pouch; use warm water to loosen the seal. Choice 4. Use the stoma guide to determine the size of the bag opening and/or protective ring. Trim as needed. Choice 5. Apply the bag with an opening no more than 1-2 mm wider than the outside of the stoma. Choice 6. Apply a skin barrier; allow the skin to dry, then connect the bag to the urine-collection device. Answer: 3, 2, 1, 4, 6, 5 Explanation: Choice 1. This is the third step. Choice 2. This is the second step. Choice 3. This is the first step. Choice 4. This is the fourth step. Choice 5. This is the last step. Choice 6. This is the fifth step. Page Ref: 890 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

32 ..

33) A patient is discharged after photocoagulation for a bladder papilloma. When should this patient be instructed to return for a follow-up evaluation with the healthcare provider? 1. 3 months 2. 1 year 3. 3 years 4. If symptoms return in the year following surgery Answer: 1 Explanation: 1. Following cystoscopic tumor resection, patients are followed at 3-month intervals for tumor recurrence. 2. Follow-up needs to be timely; 1 year would be too long. 3. Follow-up needs to be timely; 3 years would be too long. 4. The patient would be encouraged to make a follow-up appointment at any time if symptoms recur. Page Ref: 887 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

33 ..

34) A patient with a history of recurrent urinary tract infections (UTIs) asks if there are any complementary approaches to reducing the risk of developing future infections. What should the nurse instruct this patient? Select all that apply. 1. Take saw palmetto. 2. Drink blueberry juice. 3. Drink cranberry juice. 4. Limit the intake of vitamin C. 5. Apply lavender over the abdomen. Answer: 1, 3 Explanation: 1. Herbal supplements, such as saw palmetto, have a urinary antiseptic effect and may be beneficial in treating or preventing UTIs. 2. Blueberry juice is not identified to be used to prevent and treat UTIs. 3. Research supports the use of cranberry products to prevent UTIs in women with recurrent symptomatic infections. 4. Limiting vitamin C will not reduce the risk of developing UTIs. 5. Adding lavender to bathwater, not applying it to the abdomen, may relieve the discomfort of a UTI. Page Ref: 876 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.1 Describe the pathophysiology and manifestations of a urinary tract infection, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

34 ..

35) A patient with bladder cancer is scheduled for surgery to create a continent urinary reservoir. What should the nurse include when teaching the patient about this procedure? Select all that apply. 1. Electrolytes may need to be monitored. 2. The ureters are brought to the surface. 3. Part of the bowel is used for the pouch. 4. The patient will learn how to perform self-catheterization. 5. A urinary collection device is not necessary. Answer: 1, 3, 4, 5 Explanation: 1. The continent urinary reservoir may absorb urea and electrolytes, resulting in imbalances. Electrolytes may need to be monitored. 2. In a cutaneous ureterostomy, the ureters are brought to the skin surface. 3. A significant portion of the bowel is required to form the pouch and stoma of a continent urinary reservoir. 4. With a continent urinary reservoir, the patient must be able and motivated to manage selfcatheterization. 5. With a continent urinary reservoir, a drainage collection device is not necessary. Page Ref: 889 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 27.3 Describe the pathophysiology and manifestations of urinary tract tumors, and outline the interprofessional care and nursing care of patients with such disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

35 ..

36) The nurse instructs a patient with spastic bladder about the prescribed medication tolterodine (Detrol). What patient statements indicate that teaching has been effective? Select all that apply. 1. "I can take this with or without food." 2. "This medication might make me drowsy." 3. "I should call my doctor if I have problems breathing." 4. "I should be careful driving while taking this medication." 5. "I can drink wine with dinner while taking this medication." Answer: 1, 2, 3, 4 Explanation: 1. This medication can be taken irrespective of food intake. 2. This medication may cause drowsiness. 3. The patient should report any difficulty breathing. 4. The patient should use caution when driving while taking this medication. 5. The patient should not use any alcohol while taking this medication. Page Ref: 895 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with urinary tract disorders.

36 ..

37) The nurse is planning care for a patient recovering from bladder neck surgery. What should the nurse include in this patient's plan of care? Select all that apply. 1. Securing urinary catheters in position 2. Reporting any onset of bright red urine 3. Measuring urine output and reporting changes 4. Gently tugging on urinary catheter every shift 5. Expecting urine to be pink and gradually clear Answer: 1, 2, 3, 5 Explanation: 1. To maintain stability and patency, the catheter should be secured in position. 2. Bright red urine can indicate hemorrhage and should be reported. 3. Urine output should be measured and changes in output reported. 4. Pulling on catheters increases the risk for pressure on the surgical incision and should not be done. 5. Urine color after surgery will be pink and then gradually clear. Page Ref: 885 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.2 Describe the pathophysiology and manifestations of urinary calculi, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with urinary tract disorders.

37 ..

38) The nurse provides a patient with a subcutaneous dose of bethanechol chloride (Urecholine). For which manifestation should the nurse prepare to give the patient atropine? Select all that apply. 1. Voided 250 mL 2. Audible wheezes 3. Increase in heart rate 4. Drop in blood pressure 5. New onset shortness of breath Answer: 2, 3, 4, 5 Explanation: 1. Voiding is an expected effect from bethanechol chloride (Urecholine). 2. Atropine is the antidote for an adverse reaction from bethanechol chloride (Urecholine). Audible wheezes would necessitate the use of atropine. 3. Atropine is the antidote for an adverse reaction from bethanechol chloride (Urecholine). An increase in heart rate would necessitate the use of atropine. 4. Atropine is the antidote for an adverse reaction from bethanechol chloride (Urecholine). A drop in blood pressure would necessitate the use of atropine. 5. Atropine is the antidote for an adverse reaction from bethanechol chloride (Urecholine). Shortness of breath would necessitate the use of atropine. Page Ref: 895 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 27.4 Describe the pathophysiology and manifestations of disorders of urinary elimination (urinary retention, neurogenic bladder, and urinary incontinence), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with urinary tract disorders.

38 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 28 Nursing Care of Patients with Kidney Disorders 1) A patient is diagnosed with hypertension caused by polycystic kidney disease. What might be helpful to control this patient's blood pressure? 1. ACE inhibitors 2. Kidney transplant 3. Dialysis 4. Peritoneal dialysis Answer: 1 Explanation: 1. Hypertension associated with polycystic disease is generally controlled using angiotensin-converting enzyme (ACE) inhibitors or other antihypertensive agents. 2. Renal transplant is indicated when kidney function cannot control the wastes from metabolic processes. 3. Dialysis is indicated when kidney function cannot control the wastes from metabolic processes. 4. Dialysis is indicated when kidney function cannot control the wastes from metabolic processes. Page Ref: 907 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

1 ..

2) Three weeks after being treated for strep throat, a patient comes into the clinic with signs of acute glomerulonephritis. What symptom will the nurse most likely find upon assessment of this patient? 1. Periorbital edema 2. Hunger 3. Polyuria 4. Polyphagia Answer: 1 Explanation: 1. Salt and water retention increases extracellular fluid volume, which leads to hypertension and edema. The edema is primarily noted in the face, particularly around the eyes or periorbital edema. 2. Hunger (polyphagia) is symptomatic of diabetes mellitus. 3. Polyuria is symptomatic of diabetes mellitus. 4. Hunger (polyphagia) is symptomatic of diabetes mellitus. Page Ref: 908 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

2 ..

3) The nurse is planning the care of a patient with chronic glomerulonephritis. What should the nurse identify as being the goal of treatment for this patient? 1. Maintaining renal function 2. Achieving maximum independence 3. Returning to work as soon as possible 4. Lifestyle changes Answer: 1 Explanation: 1. Management of all types of glomerulonephritis—acute and chronic, primary and secondary—focuses on identifying the underlying disease process and preserving kidney function. In most glomerular disorders, there is no specific treatment to achieve a cure. Treatment goals are to maintain renal function, prevent complications and support the healing process. 2. Although maintenance of independence may be included in the plan of care, it is not a priority. 3. Although returning to work may be included in the plan of care, it is not a priority. 4. Although lifestyle adaptation may be included in the plan of care, it is not a priority. Page Ref: 910-911 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with kidney disorders.

3 ..

4) The nurse is caring for a patient with chronic glomerulonephritis. Which intervention should the nurse add to this patient's plan of care to address excess body fluid? 1. Weigh daily on the same scale. 2. Document energy level. 3. Schedule activities to conserve energy. 4. Assess for signs of infection. Answer: 1 Explanation: 1. To address excess body fluid, the nurse should add daily weights with a consistent technique to the patient's plan of care. Accurate daily weights are the best indicator of approximate fluid balance. 2. Energy level does not address the issue of excess body fluid. 3. Energy level does not address the issue of excess body fluid. 4. Signs of infection do not address the issue of excess body fluid. Page Ref: 913 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

4 ..

5) A patient with chronic kidney disease is diagnosed with hypertension. For which reason should this patient be treated to control blood pressure? 1. Reduces the risk of adverse effects on the kidneys. 2. It is the easiest diagnosis to treat. 3. Medications are available to treat this disorder. 4. Everyone should have low-normal blood pressure. Answer: 1 Explanation: 1. Management of hypertension to maintain blood pressure within normal limits the risk of adverse effects on the kidneys. 2. Hypertension is not always easily diagnosed. 3. Just because medications are available to treat the disorder is not a rationale for why blood pressure should be controlled. 4. The idea of everyone having low-normal blood pressure does not apply to this patient because of the new diagnosis and history of chronic kidney disease. Page Ref: 916 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

5 ..

6) A patient who is diagnosed with renal cancer states, "I only lost a few pounds! I had no other symptoms!" What should the nurse realize as being the only consistent symptom of renal cancer? 1. Hematuria 2. Flank pain 3. Nausea 4. Vomiting Answer: 1 Explanation: 1. Renal tumors are often silent and have few manifestations. The classic triad of symptoms, which is gross hematuria, flank pain, and palpable abdominal mass, is seen in only about 10% of people with renal cell carcinoma. Hematuria, often microscopic, is the most consistent symptom. 2. The classic triad of symptoms, which is gross hematuria, flank pain, and palpable abdominal mass, is seen in only about 10% of people with renal cell carcinoma. 3. Nausea is not a frequent symptom of renal cancer. 4. Vomiting is not a frequent symptom of renal cancer. Page Ref: 918 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

6 ..

7) The nurse is teaching a patient recovering from a nephrectomy for kidney cancer. What should the nurse include in this teaching? 1. Early recognition of a urinary tract infection (UTI) 2. Ways to limit fluids 3. Promoting high-impact sports and activities 4. Organ donor information Answer: 1 Explanation: 1. If renal cancer was detected at an early stage and cure is anticipated, teaching should focus on protecting the remaining kidney, including measures to prevent infection. 2. If renal cancer was detected at an early stage and cure is anticipated, teaching should focus on protecting the remaining kidney, including maintaining a fluid intake of 2000 to 2500 mL per day. 3. If renal cancer was detected at an early stage and cure is anticipated, teaching should focus on protecting the remaining kidney, including avoiding contact sports such as football or hockey. 4. A discussion of organ donor information is not relevant. Page Ref: 921 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

7 ..

8) An older patient is scheduled for a CT scan with and without contrast dye. What should be done prior to this CT scan? 1. Monitor renal function. 2. Assess for level of responsiveness. 3. Assess vital signs. 4. Keep the patient NPO. Answer: 1 Explanation: 1. Common nephrotoxins associated with acute tubular necrosis include radiologic contrast media. The risk for acute tubular necrosis is higher when nephrotoxic drugs are given to older patients. 2. Monitoring responsiveness is important, but does not address the specific risks of this examination. 3. Monitoring vital signs is important, but does not address the specific risks of this examination. 4. The specific location of the body for the CT scan is not indicated; therefore, it is not known if the patient would need to be kept NPO prior to the test. Page Ref: 924 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

8 ..

9) A patient with acute kidney injury (AKI) is prescribed furosemide (Lasix). Which should the nurse consider as the reason for this medication to be prescribed? 1. Reduce edema 2. Keep sodium in the body 3. Preserve protein 4. Be the gentlest diuretic to use Answer: 1 Explanation: 1. If restoration of renal blood flow does not improve urinary output, a potent loop diuretic such as furosemide may be given with intravenous fluids to help manage fluid overload. 2. Furosemide may also be used to manage salt and water retention associated with acute renal failure (ARF) as it helps to eliminate sodium. 3. Furosemide does not preserve protein. 4. Medications are not typically prescribed by their "gentleness." Each patient's response to a medication can be unique. Page Ref: 926 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

9 ..

10) A patient is scheduled to have an arteriovenous (AV) fistula created for hemodialysis. What should the nurse include when teaching the patient about this fistula? Select all that apply. 1. Avoid using the arm with the fistula for blood pressure readings. 2. A functioning fistula has a palpable pulse and bruit. 3. Ensure the use of the dominant hand and arm for placement. 4. The fistula can be used immediately after its creation. 5. Venipunctures should be performed on the arm with the fistula. Answer: 1, 2 Explanation: 1. The arm in which the fistula is placed should not be used for blood pressure, and that arm should be marked as not available for these purposes. 2. A functional arteriovenous (AV) fistula has a palpable pulse and a bruit on auscultation. 3. The nondominant arm is preferred for fistula placement. 4. It takes about a month for the fistula to mature. 5. The arm in which the fistula is placed should not be used for venipuncture and that arm should be marked as not available for these purposes. Page Ref: 929-930 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

10 ..

11) A patient who is recovering from acute kidney injury (AKI) is being discharged. What should the nurse include in this patient's instructions? 1. Avoid alcohol consumption. 2. Use over-the-counter medications as needed. 3. Instruct to weigh self at least once a month. 4. Resume a normal diet. Answer: 1 Explanation: 1. Because alcohol can increase the nephrotoxicity of some drugs, discourage alcohol ingestion. 2. Additional teaching includes avoiding exposure to nephrotoxins, particularly those found in over-the-counter products. 3. Additional teaching includes monitoring weight closely as a way to assess fluid status. Once a month is not enough. 4. Additional teaching includes dietary restrictions. Page Ref: 933 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

11 ..

12) A patient is admitted with signs of chronic kidney disease. What finding should the nurse use to determine whether this patient is developing metabolic acidosis? 1. Kussmaul respirations 2. Low urine output 3. Muscle cramps 4. Diarrhea Answer: 1 Explanation: 1. As kidney disease progresses, hydrogen-ion excretion and buffer production are impaired, leading to metabolic acidosis. Respiratory rate and depth increase, as with Kussmaul respirations, to compensate for metabolic acidosis. 2. Low urine output is often associated with chronic kidney disease and does not indicate metabolic acidosis. 3. Muscle cramps are often associated with chronic kidney disease and do not indicate metabolic acidosis. 4. Diarrhea is often associated with chronic kidney disease and does not indicate metabolic acidosis. Page Ref: 935 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

12 ..

13) A patient with diabetes and heart disease is diagnosed with chronic kidney disease. Which medication order should the nurse question for this patient? 1. Oral antihyperglycemic agent 2. Beta-blocker 3. Calcium channel blocker 4. Analgesic Answer: 1 Explanation: 1. Drugs such as metformin (Glucophage) and other oral antihyperglycemic agents eliminated by the kidney are to be avoided. 2. Beta-blockers may be used with dosage adjustment. 3. Calcium channel blockers may be used with dosage adjustment. 4. Analgesics may be used with dosage adjustment. Page Ref: 938 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

13 ..

14) A patient with chronic kidney disease is trying to decide between hemodialysis and peritoneal dialysis. What should the nurse encourage the patient to consider as advantages of peritoneal dialysis? Select all that apply. 1. Minimal vascular complications 2. Liberal intake of fluids 3. Better self-management 4. Better metabolite elimination 5. Lower risk of infection Answer: 1, 2, 3 Explanation: 1. Peritoneal dialysis has several advantages over hemodialysis. Heparinization and vascular complications associated with an arteriovenous (AV) fistula are avoided. 2. More liberal intake of fluid and nutrients is often allowed for the patient on continuous ambulatory peritoneal dialysis (CAPD). 3. The patient on peritoneal dialysis is better able to self-manage the treatment regimen, which reduces feelings of helplessness. 4. The major disadvantages of peritoneal dialysis include less effective metabolite elimination. 5. The major disadvantages of peritoneal dialysis include risk for infection (peritonitis). Page Ref: 930-931 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

14 ..

15) A patient who received a kidney transplant seven years ago is seen for increasing blood pressure and proteinuria. Of what health problem is this patient demonstrating signs? 1. Chronic rejection 2. Acute rejection 3. Renal artery stenosis 4. Pyelonephritis Answer: 1 Explanation: 1. Chronic rejection may develop months to years following transplant. The manifestations of azotemia, proteinuria, and hypertension are those of progressive kidney disease. 2. Acute rejection most commonly occurs in the weeks that immediately follow transplant. 3. Renal artery stenosis manifests with a bruit over the surgical anastomosis site. 4. Pyelonephritis manifests with abdominal discomfort and low-grade fever. Page Ref: 941 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

15 ..

16) The nurse is planning care for a patient with kidney disease who is having difficulty maintaining adequate nutrition. Which intervention should the nurse include in this patient's plan of care? 1. Provide mouth care before meals. 2. Schedule meals for three times each day. 3. Provide antiemetics after meals. 4. Weigh once per week. Answer: 1 Explanation: 1. Mouth care improves taste, stimulates the appetite, and maintains the integrity of oral mucous membranes. 2. The patient would benefit from small meals and between-meal snacks. 3. Antiemetics should be administered 30 to 60 minutes before meals. 4. The patient should be weighed daily before breakfast. Page Ref: 943 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

16 ..

17) The nurse is preparing to assess an older patient with age-related renal dysfunction. What should the nurse include in this assessment? 1. Evidence of medication or drug toxicity 2. Recreational activities 3. Activity status 4. Daily meal pattern Answer: 1 Explanation: 1. With age-related changes in kidney function, there is a decrease in glomerular filtration rate (GFR). This can lead to a decrease in the clearance of drugs, primarily through the kidneys. The nurse should assess this patient for drug toxicity. 2. Recreational activities may or may not be affected. 3. Activity status may or may not be affected. 4. Meal patterns may or may not be affected. Page Ref: 911 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

17 ..

18) A patient is diagnosed with postrenal acute kidney injury (AKI). What should the nurse suspect caused this patient's type of kidney injury? 1. Benign prostatic hypertrophy 2. Hypovolemia 3. Sepsis 4. Drug toxicity Answer: 1 Explanation: 1. Causes for postrenal AKI include benign prostatic hypertrophy. 2. Hypovolemia would be considered a prerenal cause of AKI. 3. Sepsis would be considered a prerenal cause of AKI. 4. Drug toxicity would be considered a prerenal cause of AKI. Page Ref: 923 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

18 ..

19) A patient with polycystic kidney disease is planning to be married and asks the nurse if his children could inherit this disorder. What is the nurse's best response? 1. "Yes, this condition can be inherited." 2. "Yes, but this condition is so rare that you shouldn't worry about it." 3. "No, polycystic kidney disease occurs because of spontaneous mutations." 4. "You should ask your fiancée to come with you to your next office visit so we can discuss this." Answer: 1 Explanation: 1. Autosomal dominant polycystic kidney disease is relatively common, affecting 1 in every 400 to 1000 people and accounts for 4% of ESRD in the United States. Approximately 90% of cases are inherited as an autosomal dominant trait and the remaining 10% are due to spontaneous mutations. 2. This response gives the patient potentially false information. 3. Approximately 90% of cases are inherited as an autosomal dominant trait and the remaining 10% are due to spontaneous mutations. 4. This does not answer the patient's question. Page Ref: 906 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

19 ..

20) The nurse is completing the instructions to a patient who underwent a cadaver kidney transplant and is ready for discharge from the hospital. What patient statement indicates that further teaching is needed? 1. "I'm glad I won't have to take immunosuppressants any longer." 2. "I know to check my weight on a regular basis." 3. "I'll call my doctor if I notice any decrease in my urine output." 4. "I'll tell my friends to stay away from me if they have colds or the flu." Answer: 1 Explanation: 1. Unless the donor and recipient are identical twins, immunosuppressants are taken to minimize the immune response to reject the transplanted organ. 2. The patient will need to check weight on a regular basis. 3. The patient should contact the physician with any decreases in urine output. 4. The patient should also avoid individuals who have colds or the flu. Page Ref: 940 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

20 ..

21) The nurse is evaluating the effectiveness of dietary teaching provided to a patient with chronic kidney disease. Which menu choices indicate that the patient understands the dietary regimen? 1. Apple and oatmeal for breakfast; peanut butter sandwich for lunch; pasta with fish for dinner 2. Bacon and eggs for breakfast; hot dog with sauerkraut for lunch; baked canned ham with green peas for dinner 3. Two bananas for breakfast; rice and beans for lunch; fruit salad, green beans, and an 8-ounce steak for dinner 4. Half a cantaloupe and three eggs for breakfast; a baked potato with processed cheese spread and broccoli for lunch; chicken, pinto beans, squash, and pecan pie for dinner Answer: 1 Explanation: 1. The patient with chronic kidney disease needs to adhere to a low-protein, sodium- and potassium-restricted diet. These menu choices adhere to the dietary regimen. 2. Processed foods (canned ham, sauerkraut, cheese spread) contain high levels of sodium, which is restricted. 3. These menu choices include excessive amounts of potassium (bananas) and protein, which are restricted. 4. These menu choices include processed foods (canned ham, sauerkraut, cheese spread) that contain high levels of sodium, which is restricted. Page Ref: 938-939 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

21 ..

22) The nurse is caring for a patient receiving peritoneal dialysis. After completing the exchange and draining the dialysate, the nurse notices that the dialysate is cloudy. How should the nurse interpret this finding? 1. A sign of infection 2. A sign of vascular access occlusion 3. The normal appearance of dialysate 4. A sign of possible bowel perforation Answer: 1 Explanation: 1. Dialysate is typically clear; cloudy or malodorous dialysate may indicate infection. 2. Peritoneal dialysis does not use vascular access. 3. Dialysate is typically clear. 4. Blood or feces in the dialysate may indicate organ or bowel perforation. Page Ref: 944 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with kidney disorders.

22 ..

23) The nurse is teaching a patient about hemodialysis. How should the nurse explain this process? 1. It moves blood through a semipermeable membrane into a dialyzer that is used to remove waste products as well as correct fluid and electrolyte imbalances. 2. It allows a choice of either diffusion osmosis or ultrafiltration to remove excess water from the body. 3. It adds potassium to the blood when passing through the dialyzer and works on the principle of diffusion. 4. It will add electrolytes and water to the blood when passing through a semipermeable membrane to correct electrolyte imbalances. Answer: 1 Explanation: 1. Hemodialysis uses the principles of diffusion and ultrafiltration to remove electrolytes, waste products, and excess water from the body. Blood is taken from the patient and pumped into the dialyzer, where a semipermeable membrane allows small molecules to pass through. 2. Hemodialysis uses both principles of diffusion and ultrafiltration to remove electrolytes. 3. Hemodialysis removes electrolytes from the body and works on the principles of diffusion and ultrafiltration. 4. Hemodialysis removes electrolytes and excess water from the body. Page Ref: 928 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

23 ..

24) At the conclusion of a health history the nurse determines that a patient is at risk for kidney cancer. What did the nurse assess to make this clinical decision? Select all that apply. 1. Obesity 2. Over 55 years of age 3. Genetic predisposition 4. Female 5. Bladder calculi Answer: 1, 2, 3 Explanation: 1. Risk factors for the development of kidney cancer include obesity. 2. Risk factors for the development of kidney cancer include age greater than 55. 3. Risk factors for the development of kidney cancer include having a genetic predisposition to the disease. 4. Males are affected more than females by a 2:1 ratio. 5. Bladder calculi are not identified as increasing the risk of kidney cancer. Page Ref: 918 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

24 ..

25) The nurse administers epoetin alfa (Epogen) to a patient on dialysis. What should the nurse expect the therapeutic effect of this medication to be? 1. It treats the anemia seen in chronic kidney disease patients on dialysis. 2. It combats the effects of dialysis on bone marrow. 3. It promotes elimination of nephrotoxic drugs from the body. 4. It enhances absorption of iron and folate in the intestinal tract. Answer: 1 Explanation: 1. In chronic kidney disease, erythropoietin production in the kidney declines, which suppresses RBC production leading to anemia. Erythropoiesis-stimulating agents such as epoetin alfa increase RBC production. 2. Epoetin alfa has no action on bone marrow. 3. Epoetin alfa does not promote elimination of nephrotoxic drugs from the body. 4. Epoetin alfa does not affect absorption of iron or folate. Page Ref: 938 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

25 ..

26) A patient with an acute kidney injury is prescribed sodium polystyrene sulfonate (Kayexalate). What should the nurse instruct the patient regarding the expected effect of this medication? 1. Remove potassium. 2. Replace sodium. 3. Replace magnesium. 4. Exchange calcium for sodium. Answer: 1 Explanation: 1. Sodium polystyrene sulfonate (Kayexalate) is given to remove potassium in the patient with acute kidney injury by exchanging sodium for potassium, primarily in the large intestine. 2. Sodium polystyrene sulfonate (Kayexalate) is not used to replace sodium. 3. Sodium polystyrene sulfonate (Kayexalate) is not used to replace magnesium. 4. Sodium polystyrene sulfonate (Kayexalate) does not exchange calcium for sodium. Page Ref: 938 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

26 ..

27) The nurse is preparing to administer an osmotic diuretic to a patient. What should the nurse do when providing this medication? Select all that apply. 1. Check solution for crystallization prior to IV administration. 2. Evaluate urine output after test dose is given. 3. Assess for signs of worsening heart failure. 4. Assess for orthostatic hypotension. 5. Monitor patient for signs of ototoxicity. Answer: 2, 3 Explanation: 1. There is no documentation that these solutions crystallize. 2. A test dose may be given, and urine output is evaluated for an adequate response. 3. The patient should be assessed for signs of worsening heart failure because of the increased vascular volume that occurs with these medications. 4. Orthostatic hypotension is not an issue due to the increase in intravascular volume but should be assessed when giving loop diuretics. 5. Ototoxicity is a concern with high doses of loop diuretics. Page Ref: 927 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with kidney disorders.

27 ..

28) A patient recovering from a total nephrectomy is being discharged. What should the nurse instruct the patient about care at home? Select all that apply. 1. Avoid contact sports and falls. 2. Older males should schedule routine screening examinations for prostatic hypertrophy. 3. Monitor weight. 4. Monitor for signs of rejection. 5. Maintain prescribed fluid restrictions. Answer: 1, 2 Explanation: 1. Home care teaching focuses on protecting the remaining kidney by avoiding contact sports and using measures to prevent motor vehicle accidents and falls that could damage it. 2. Older male patients should know manifestations of prostatic hypertrophy and schedule routine screening examinations. 3. Monitoring weight is a concern for the patient after a kidney transplant. 4. Noting any signs of rejection is a concern for the patient after a kidney transplant. 5. Maintaining prescribed fluid restrictions is a concern for the patient after a kidney transplant. Page Ref: 919, 921 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

28 ..

29) During the assessment the nurse suspects a patient with injuries from a motor vehicle crash sustained kidney trauma. What did the nurse assess to make this clinical decision? Select all that apply. 1. Turner sign 2. Nausea and vomiting 3. Microscopic hematuria 4. Blood pressure 88/58 mmHg 5. Heart rate 118 beats per minute Answer: 1, 3, 4, 5 Explanation: 1. In kidney trauma, retroperitoneal bleeding from the kidney may cause Turner sign, a bluish discoloration of the flank. 2. Nausea and vomiting are not manifestations of kidney trauma. 3. The primary manifestation of kidney trauma includes microscopic hematuria. 4. In kidney trauma, signs of shock such as hypotension can occur. 5. In kidney trauma, signs of shock such as tachycardia can occur. Page Ref: 917 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.1 Describe the pathophysiology and manifestations of kidney disorders, including polycystic kidney disease, glomerular disorder, vascular kidney disorder, kidney trauma, and renal tumor, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with kidney disorders.

29 ..

30) A patient is in the recovery phase of acute tubular necrosis (ATN). What manifestation should the nurse observe that indicates this phase is progressing as expected? Select all that apply. 1. Elevated serum potassium level 2. Urine output excessive for intake 3. Elevated blood urea nitrogen level 4. Decrease in serum phosphate level 5. Urine output low in relation to intake Answer: 1, 2, 3 Explanation: 1. The recovery phase of ATN is characterized by a process of tubule cell repair and regeneration and gradual return of the GFR to normal. Serum potassium levels remain high and may continue to rise in spite of increasing urine output. 2. The recovery phase of ATN is characterized by a process of tubule cell repair and regeneration and gradual return of the GFR to normal. Diuresis may occur as the nephrons and GFR recover. 3. The recovery phase of ATN is characterized by a process of tubule cell repair and regeneration and gradual return of the GFR to normal. BUN levels remain high and may continue to rise in spite of increasing urine output. 4. The recovery phase of ATN is characterized by a process of tubule cell repair and regeneration and gradual return of the GFR to normal. Serum phosphate levels remain high and may continue to rise in spite of increasing urine output. 5. The recovery phase of ATN is characterized by a process of tubule cell repair and regeneration and gradual return of the GFR to normal. Diuresis occurs as the nephrons and GFR recover. Page Ref: 924 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with kidney disorders.

30 ..

31) A patient weighing 209 lbs. is suspected of being in stage 2 of an acute kidney injury. If the nurse uses the standard output of 0.5 mL/kg/hr, what is the maximum amount of urine that this patient should produce for 18 hours to confirm this stage of kidney injury? Record your answer rounding to the nearest whole number. Answer: 855 mL Explanation: To calculate this patient's weight in kilograms, divide the weight in lbs. by 2.2. The patient weighs 209 lbs. divided by 2.2 = 95 kg. Then use the equation 0.5 mL × 95 = 47.5 mL/hr. To calculate the maximum amount of urine that this patient should produce over 18 hours, multiple the hourly amount of 47.5 mL × 18 = 855 mL. Page Ref: 925 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with kidney disorders.

31 ..

32) A patient with chronic kidney disease is prescribed a diet containing 0.75 gram of protein per kilogram of body weight per day. The patient weighs 231 lbs. How many grams of protein should the nurse instruct the patient to ingest each day? Calculate to the nearest whole number. Answer: 79 grams Explanation: To calculate this patient's weight in kilograms, divide the weight in lbs. by 2.2 or 231/2.2 = 105 kg. Then multiply the prescribed amount of protein by the weight in kilogram or 0.75 gram × 105 = 78.75 grams. When rounded, the patient should be instructed to ingest 79 grams of protein each day. Page Ref: 939 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 28.2 Describe the pathophysiology and manifestations of kidney failure (i.e., acute kidney injury and chronic kidney disease), and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with kidney disorders.

32 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 29 Assessing the Cardiovascular and Lymphatic Systems 1) The nurse is reviewing the anatomy of the heart with a patient scheduled for a cardiac catheterization. What should the nurse explain as the primary factor that regulates blood flow through the coronary arteries? 1. Blood pressure in the aorta 2. Blood vessel dilation 3. Low-pressure systemic circulation 4. Draining of blood into the coronary sinus by the coronary veins Answer: 1 Explanation: 1. Blood flow through the coronary arteries is primarily regulated by the aortic blood pressure. 2. Blood vessel dilation is a secondary factor that regulates blood flow through the coronary arteries. 3. The systemic circulation is a high-pressure circulation system. 4. Draining of blood into the coronary sinus by the coronary veins does not regulate blood flow through the coronary arteries. Page Ref: 956 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

1 ..

2) The nurse is explaining cardiac reserve to a patient recovering from a myocardial infarction. Which example should the nurse use to explain this term? 1. Getting on a treadmill and gradually increasing the pace of walking 2. Breathing in through the nose and out the mouth while sitting quietly 3. Sitting in a chair to cool down after completing an exercise routine 4. At the end of systole, approximately 50 mL of blood remaining in the ventricles Answer: 1 Explanation: 1. The heart's ability to respond to the body's changing needs for cardiac output is called cardiac reserve. Increasing the pace of walking would place demand on the heart to increase blood flow. 2. This action does not illustrate cardiac reserve. 3. This action does not illustrate cardiac reserve. 4. This action does not illustrate cardiac reserve. Page Ref: 956 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

2 ..

3) The nurse is reviewing the layers of the heart with a patient with endocarditis. From outermost to innermost, in which order should the nurse review these layers? Place the six steps in the correct order. Choice 1. Epicardium Choice 2. Myocardium Choice 3. Endocardium Choice 4. Pericardial cavity Choice 5. Fibrous pericardium Choice 6. Parietal layer of serous pericardium Answer: 5, 6, 4, 1, 2, 3 Explanation: Choice 1. The epicardium lies beneath the pericardial cavity. Choice 2. The myocardium lies beneath the epicardium. Choice 3. The endocardium is the innermost layer of the heart. Choice 4. The pericardial cavity lies beneath the parietal layer. Choice 5. The fibrous pericardium is the outermost layer of the heart. Choice 6. The parietal layer of serous pericardium lies beneath the fibrous pericardium. From outermost to innermost layer, the layers of the heart are the fibrous pericardium, the parietal layer of serous pericardium, the pericardial cavity, the epicardium, the myocardium, and the endocardium. Page Ref: 954 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

3 ..

4) A patient being evaluated for cardiac pathology asks the nurse why sodium, calcium, and potassium are so important in the diet. What is the nurse's best response? 1. "The action potentials of the heart muscle cells are dependent on the diffusion of sodium, potassium, and calcium across the cell membrane." 2. "Because you are on potassium supplements, it is important to monitor electrolytes." 3. "Heart rate is affected by the oxygen levels in your body, which involves the attachment of oxygen molecules to these electrolytes." 4. "It is the pacemaker of your heart that is responsible for the heartbeat." Answer: 1 Explanation: 1. Action potentials of the cardiac muscle involve shifts in potassium, calcium, and sodium across the cell membrane. 2. There is not enough data to justify this response. 3. Oxygen molecules attach to the hemoglobin molecule, not electrolytes. 4. The pacemaker is responsible for the heartbeat, but this response does not address the patient's question. Page Ref: 957 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

4 ..

5) The nurse is planning to calculate a patient's cardiac index (CI). What physical assessment data does the nurse need to make this calculation? 1. Weight and height 2. Weight only 3. Weight and waist measurement 4. Waist measurement and height Answer: 1 Explanation: 1. Cardiac index (CI) is the cardiac output adjusted for body size or body surface area. Body surface area is calculated using height and weight measurements. 2. The weight measurement alone is insufficient to calculate CI. 3. The waist measurement is not needed to calculate CI. 4. The waist measurement is not needed to calculate CI. Page Ref: 957 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

5 ..

6) The nurse is preparing to analyze a patient's electrocardiogram (ECG) rhythm strip. In which order should the nurse complete this analysis? Place the six steps in the correct order. Choice 1. Determine rate. Choice 2. Assess P wave. Choice 3. Determine regularity. Choice 4. Identify abnormalities. Choice 5. Assess P-to-QRS relationship. Choice 6. Determine interval durations. Answer: 1, 3, 2, 5, 6, 4 Explanation: Choice 1. The first step in this process is to determine rate. Choice 2. The third step is to assess the P wave. Choice 3. The second step is to determine regularity. Choice 4. The sixth step is to identify abnormalities. Choice 5. The fourth step is to assess P-to-QRS relationship. Choice 6. The fifth step is to determine interval durations. Page Ref: 985 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

6 ..

7) The nurse is reviewing an electrocardiogram (ECG) rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 second and QRS complexes measure 0.06 second. The overall heart rate is 64 beats/minute. What should the nurse interpret these findings as indicating? 1. Normal heart function 2. Sick sinus syndrome 3. Sinus bradycardia 4. First-degree heart block Answer: 1 Explanation: 1. All the measurements are within normal limits. The PR and QRS measurements are normal, measuring 0.12 to 0.20 second and 0.06 to 0.10 second, respectively. 2. There is not enough information to determine if the patient is experiencing sick sinus syndrome. 3. Bradycardia is a heart rate of less than 60 beats per minute. 4. There is not enough information to determine if the patient is experiencing first-degree heart block. Page Ref: 984 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

7 ..

8) The nurse is preparing to auscultate a patient's heart sounds. At which location will S1 be heard the loudest? 1. Left midclavicular line at the fifth intercostal space 2. Left sternal border at the fifth intercostal space 3. Right midclavicular line at the fifth intercostal space 4. Right sternal border at the third intercostal space Answer: 1 Explanation: 1. S1 is the sound produced by the atrioventricular (AV) valves closing and is heard the best at the left midclavicular line, fifth intercostal space. 2. The sound is audible at the left sternal border, but would not be as loud. 3. This sound would not normally be audible on the right midclavicular line at the fifth intercostal space. 4. This sound would not normally be audible at the sternal border. Page Ref: 971 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

8 ..

9) The nurse is caring for a patient with hypovolemic shock. In which way will this patient's heart sounds change? 1. Diminished S2 2. Accentuated S2 3. Diminished S1 and S2 4. No change in S1 or S2 Answer: 1 Explanation: 1. The S2 sound diminishes due to a fall in blood pressure and shock. 2. An accentuated S2 may be heard with HTN, exercise, excitement, and conditions of pulmonary HTN such as CHF and cor pulmonale. 3. S1 diminishes with first-degree heart block, mitral regurgitation, CHF, CAD, and pulmonary or systemic HTN. 4. The nurse should expect a change in the S2 sound. Page Ref: 971 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

9 ..

10) When listening to heart sounds, the nurse hears an S3 sound after S2. What should the nurse suspect is occurring with this patient? 1. Ventricular volume overload 2. Increased resistance to ventricular filling 3. Inflammation of the pericardial sac 4. Stenotic mitral valve Answer: 1 Explanation: 1. A pathologic S3 is called a ventricular gallop and results from myocardial failure and ventricular volume overload. 2. An S3 sound is not caused by increased resistance to ventricular filling. 3. An S3 sound is not caused by inflammation of the pericardial sac. 4. An S3 sound is not caused by mitral valve stenosis. Page Ref: 972 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

10 ..

11) The nurse is caring for a patient admitted with a grade III heart murmur heard at midsystole. Which heart problem causes this type of murmur? Select all that apply. 1. Aortic stenosis 2. Cardiomyopathy 3. Atrioventricular (AV) valve disease 4. Mitral valve prolapse (MVP) 5. Ventricular septal defect Answer: 1, 2 Explanation: 1. Midsystolic murmurs are associated with semilunar valve diseases such as aortic stenosis. 2. Midsystolic murmurs are associated with hypertrophic cardiomyopathies. 3. Pansystolic (holosystolic) murmurs are heard with AV valve disease. 4. A late systolic murmur is heard with MVP. 5. Pansystolic (holosystolic) murmurs are heard with AV valve diseases such as ventricular septal defect. Page Ref: 972 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

11 ..

12) The patient's ECG shows the following characteristics: PR interval .08, QRS .08, and isoelectric ST segment. What should the nurse realize these findings indicate? 1. Faster than normal conduction from the SA node to the ventricles, normal conduction through the ventricles, and normal ST segment 2. Faster than normal conduction from the SA node to the ventricles, faster than normal conduction through the ventricles, and normal ST segment 3. Normal conduction from the SA node to the ventricles, normal conduction through the ventricles, and normal ST segment 4. Normal conduction from the SA node to the ventricles, normal conduction through the ventricles, and abnormal ST segment Answer: 1 Explanation: 1. The PR interval is normally 0.12 second (up to 0.24 second is considered normal in patients over age 65). 2. The normal duration of a QRS complex is 0.06 to 0.10 second. 3. The PR interval is normally 0.12 second (up to 0.24 second is considered normal in patients over age 65). 4. The ST segment, the period from the end of the ARS complex to the beginning of the T wave, should be isoelectric. Page Ref: 984 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

12 ..

13) The patient is performing a treadmill test. What should the nurse instruct the patient about this test? 1. The patient should wear comfortable shoes. 2. The patient should wear a patient gown and slippers. 3. Smoking is permitted until the time of the test. 4. There are no dietary restrictions prior to the test as long as small meals are planned for the day of the test. Answer: 1 Explanation: 1. For the treadmill test, the patient should be asked to wear comfortable shoes. 2. Slippers may not be safe; secure shoes should be worn because speed is increased during the test. 3. Smoking is discouraged prior to testing. 4. The patient should be instructed to avoid food and fluids for 2 to 3 hours before the test. Page Ref: 981 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the cardiovascular and lymphatic systems.

13 ..

14) The patient is being evaluated for left atrium thrombus due to a dysrhythmia. Which diagnostic test should the nurse expect to be prescribed for this patient? 1. Transesophageal echocardiography (TEE) 2. Pericardiocentesis 3. Cardiac catheterization 4. Computed tomography (CT) Answer: 1 Explanation: 1. Transesophageal echocardiography (TEE) allows visualization of the left atrium for thrombus. 2. Pericardiocentesis is a procedure to remove fluid from the pericardial sac. 3. Cardiac catheterization is used to identify coronary artery disease (CAD) or valve disease, measure pulmonary artery or heart chamber pressures, obtain a biopsy, evaluate artificial valves, or perform angioplasty or stent an area in the coronary arteries. 4. A computed tomography (CT) scan can show calcium deposits in coronary arteries. Page Ref: 981 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the cardiovascular and lymphatic systems.

14 ..

15) A patient is scheduled for a cardiac catheterization. In which order should the nurse describe the events in this diagnostic test? Place the four events in the correct order. Choice 1. Contrast dye is injected. Choice 2. Heart activity is filmed. Choice 3. A catheter is inserted into a vein or artery in the leg. Choice 4. The catheter is threaded to the heart chamber. Answer: 3, 4, 1, 2 Explanation: Choice 1. Once the catheter is in the heart chamber, contrast dye is injected. This is the third step. Choice 2. The last step is filming heart activity. Choice 3. The first step is inserting the catheter into the leg. Choice 4. After insertion, the catheter is threaded to the heart chamber. This is the second step. Page Ref: 978 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the cardiovascular and lymphatic systems.

15 ..

16) A patient is scheduled for a pericardiocentesis. Which health problem is the patient likely experiencing? 1. Cardiac tamponade 2. Slow heart rhythm 3. Chest pain 4. Suspected damage to a heart valve Answer: 1 Explanation: 1. In the case of cardiac tamponade, pericardiocentesis is considered an emergency procedure. It is done to remove fluid from the pericardial sac, which is preventing the heart from pumping blood effectively. 2. This procedure would not be recommended for patients with chest pain. 3. This procedure would not be recommended for patients with slow heart rhythm. 4. This procedure would not be recommended for patients with suspected damage to a heart valve. Page Ref: 980 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the cardiovascular and lymphatic systems.

16 ..

17) The nurse palpates a thrill on a patient's precordium. With which health problem should the nurse associate this finding? 1. Severe valve stenosis 2. Enlarged heart 3. Stenosis of the carotid arteries 4. Aortic aneurysm Answer: 1 Explanation: 1. A palpable thrill over the precordium indicates severe valve stenosis. 2. A thrill is not present when the heart is merely enlarged. 3. Stenosis of the carotid arteries would produce a thrill palpable on the neck over the carotid arteries, not the precordium. 4. Increased pulsations in the aortic area indicate an aortic aneurysm. Page Ref: 970 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

17 ..

18) The nurse is completing the health history of a patient with a suspected cardiac disorder. About which childhood illnesses should the nurse ask the patient? 1. Rheumatic fever and strep throat infections 2. Rubella and chickenpox 3. Asthma and bronchitis 4. Otitis media and respiratory syncytial virus (RSV) Answer: 1 Explanation: 1. Rheumatic fever and streptococcal throat infections are caused by betahemolytic streptococci, which have a propensity to form growths and calcium deposits on the leaflets of heart valves. This sets the individual up for valvular stenosis. 2. Rubella and chickenpox are not directly related to cardiac disorders. 3. Asthma and bronchitis are not directly related to cardiac disorders. 4. Otitis media and respiratory syncytial virus are not directly related to cardiac disorders. Page Ref: 969 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

18 ..

19) When auscultating heart sounds, the nurse asks the patient to lie on the left side, then sit up and lean forward. Why is the patient asked to move into these positions? 1. The heart is closer to the chest wall. 2. They diminish the effect of respiratory sounds during auscultation. 3. Use of the stethoscope diaphragm improves auscultation of high-pitched murmurs. 4. Use of the bell side of the stethoscope allows low-pitched sounds to be readily identified. Answer: 1 Explanation: 1. These positions bring the heart closer to the chest wall and enhance auscultation. 2. These positions do not diminish the effect of respiratory sounds during auscultation. 3. These positions do not enhance the use of the stethoscope diaphragm to auscultate highpitched murmurs. 4. These positions do not enhance the use of the stethoscope bell to identify low-pitched sounds. Page Ref: 971 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

19 ..

20) A patient recovering from a cardiac catheterization asks to be left alone. What should the nurse explain to this patient? 1. "It is important that you drink fluids after the procedure to protect kidney function. I will bring you some fresh water." 2. "It is important that you ambulate, so I will return in 30 minutes to walk with you." 3. "You are recovering well from the procedure, and rest is a good idea." 4. "You need to do the leg exercises that you practiced before the procedure to maintain good circulation to your legs. After your exercises, you can rest." Answer: 1 Explanation: 1. The dye used in angiography is nephrotoxic, and the patient should have adequate fluids after the procedure to eliminate the dye. 2. The patient should lie with the affected leg extended for the prescribed period of time. 3. There is no evidence that the patient is recovering well. 4. Leg exercises are not recommended as they could dislodge the clot at the insertion site. Page Ref: 978 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the cardiovascular and lymphatic systems.

20 ..

21) A patient has a stroke volume (SV) of 80 mL/beat and a heart rate (HR) of 75 beats/minute. What should the nurse calculate this patient's cardiac output to be? ________ mL Record your answer rounding to the nearest whole number. Answer: 6000 Explanation: Cardiac output is the amount of blood pumped by the ventricles into the pulmonary and systemic circulations in 1 minute. It is determined by multiplying the stroke volume by the heart rate (SV × HR = CO). Multiplying 80 mL/beat by 75 beats/minute equals 6000 mL. Page Ref: 956 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems. 22) A patient has a stroke volume (SV) of 75 mL/beat and end-diastolic volume of 120 mL. What should the nurse calculate this patient's ejection fraction to be? ________% Record your answer rounding to the nearest whole number. Answer: 63 Explanation: The ejection fraction is the stroke volume divided by the end-diastolic volume and represents the fraction or percent of the diastolic volume that is ejected from the heart during systole. The normal ejection fraction ranges from 50% to 70%. Dividing 75 mL/beat by 120 mL equals 63%. Page Ref: 956 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of 21 ..

these body systems. 23) A patient returns to the care area after a cardiac catheterization. Which nursing intervention is appropriate for this patient? Select all that apply. 1. Assess cardiac rhythm and rate. 2. Assess patient for complaints of shortness of breath. 3. Maintain bed rest as ordered. 4. Assess pulses proximal to the insertion site. 5. Maintain fluid restriction. Answer: 1, 2, 3 Explanation: 1. Nursing interventions after cardiac catheterization procedure include monitoring vital signs every 15 minutes for the first hour and then every 30 minutes until stable. Cardiac rhythm and rate should be assessed for alterations. 2. The patient should be assessed for complaints of chest heaviness, shortness of breath, and abdominal or groin pain. 3. The patient should remain on bed rest as ordered. 4. Pulses distal, not proximal, to the insertion site should be assessed. 5. Oral fluids should be encouraged unless contraindicated. Page Ref: 978 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the cardiovascular and lymphatic systems.

22 ..

24) The nurse is assessing an adult patient's heart sounds. In which order should the nurse hear the sounds? 1. S1, then S2 2. S2, then S3 3. S3, then S4 4. S2, then S1 Answer: 1 Explanation: 1. The normal sequence of heart sounds is S1, then S2. 2. S3 and S4 are considered abnormal heart sounds in adults. 3. S3 and S4 are considered abnormal heart sounds in adults. 4. This is not the normal sequence of heart sounds. Page Ref: 971 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

23 ..

25) The nurse determines that a patient has tachycardia. What does this information suggest about the patient's heart rate? 1. Greater than 100 beats per minute 2. Less than 60 beats per minute 3. 60-90 beats per minute 4. 90 beats per minute Answer: 1 Explanation: 1. The normal heart rate range is 60-100 beats per minute. A heart rate greater than 100 beats per minute is called tachycardia. 2. A heart rate that is less than 60 beats per minute is called bradycardia. 3. A heart rate between 60 and 90 beats per minute would be considered within the normal range. 4. A heart rate between 60 and 90 beats per minute would be considered within the normal range. Page Ref: 971 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

24 ..

26) When auscultating the chest of an older patient who recently experienced a myocardial infarction (MI), the nurse hears an S3 heart sound immediately following S2. For which other health problems should the nurse assess this patient? 1. Heart failure 2. Extension of the MI 3. Renal failure 4. Liver failure Answer: 1 Explanation: 1. A pathologic S3 (a third heart sound that immediately follows S2, called a ventricular gallop) results from myocardial failure and ventricular volume overload such as heart failure. 2. Manifestations of MI extension include chest pain and a return of positive laboratory findings (CPK-MB and troponin). 3. This heart sound is not associated with renal failure. 4. This heart sound is not associated with liver failure. Page Ref: 972 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

25 ..

27) The nurse is listening to the heart of a healthy young adult. How many beats per minute should the nurse expect to assess in this patient? 1. 60-100 2. 30-60 3. 100-130 4. 130-160 Answer: 1 Explanation: 1. The heart rate of a healthy young adult should be 60-100 beats per minute (bpm), with regular rhythm. 2. A rate less than 60 is bradycardia. 3. A rate greater than 100 is tachycardia. 4. A rate greater than 100 is tachycardia. Page Ref: 953 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.1 Describe the anatomy, physiology, and functions of the cardiovascular and lymphatic systems. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

26 ..

28) An older patient is being treated for sepsis. What intervention should the nurse include in this patient's plan of care to adjust for age-related changes in cardiovascular status? Select all that apply. 1. Restricting fluids 2. Monitoring for tachycardia 3. Encouraging increased physical activity 4. Planning rest periods between physical activities 5. Maintaining the head of the bed at a 30-degree angle Answer: 2, 4 Explanation: 1. Restricting fluids will not help with age-related changes in the cardiovascular system. 2. One age-related change in the cardiovascular system is a reduction in myocardial efficiency and contractility. Cardiac output decreases under physiologic stress, resulting in tachycardia that lasts longer. 3. Encouraging physical activity can lead to additional symptoms because of age-related changes to the myocardium. 4. One age-related change in the cardiovascular system is a reduction in myocardial efficiency and contractility. Cardiac output decreases under physiologic stress. The patient may require rest time between physical activities. 5. There is no need to maintain the head of the bed at a 30-degree angle. Page Ref: 986 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.4 Differentiate considerations for assessing the cardiovascular and lymphatic systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

27 ..

29) During an assessment the nurse determines that an older patient is demonstrating agerelated changes in the tunica intima layer of the vascular system. What did the nurse assess to make this clinical determination? Select all that apply. 1. Tachycardia 2. Postural hypotension 3. Weak peripheral pulses 4. Prominent neck and hand veins 5. Elevated systolic blood pressure Answer: 2, 4, 5 Explanation: 1. Tachycardia is a result of reduced myocardial efficiency and contractility. 2. Age-related changes in the tunica intima of blood vessels cause fibrosis, calcium and lipid accumulation, and cellular proliferation. Changes in baroreceptor function within the arteries lead to postural hypotension. 3. Weak peripheral pulses are not an expected age-related change in the vascular system. 4. Age-related changes in the tunica intima of blood vessels cause fibrosis, calcium and lipid accumulation, and cellular proliferation. Vessels in the head, neck, and extremities are more prominent. 5. Age-related changes in the tunica intima of blood vessels cause fibrosis, calcium and lipid accumulation, and cellular proliferation. These changes cause an increase in systolic blood pressure. Page Ref: 986 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.4 Differentiate considerations for assessing the cardiovascular and lymphatic systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

28 ..

30) An older patient asks why she always feels so cold. What should the nurse's response include? Select all that apply. 1. "Heat sensors in the blood vessels lose sensitivity with aging." 2. "Your body metabolism is slowing the amount of blood flow." 3. "Blood vessels don't constrict as quickly with aging." 4. "Aging causes a layer of the blood vessels to stiffen." 5. "One layer of the blood vessels gets thinner with aging." Answer: 3, 4, 5 Explanation: 1. There is no evidence that heat sensors in the blood vessels lose sensitivity as an age-related change. 2. Slowing of the metabolism does not necessarily slow the amount of blood flow. 3. Age-related changes to the tunica media layer of the blood vessels cause inefficient vasoconstriction. 4. With aging, the elastin fibers within the tunica media calcify, which leads to stiffening and inefficient vasoconstriction. 5. The tunica media layer thins with aging. Page Ref: 986 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.4 Differentiate considerations for assessing the cardiovascular and lymphatic systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

29 ..

31) The nurse is planning care for an older patient who exhibits low blood pressure. What should the nurse include in this plan that addresses age-related vascular changes? Select all that apply. 1. Monitoring hemoglobin level 2. Monitoring the effects of medications 3. Encouraging frequent position changes 4. Monitoring lower extremities for edema 5. Assessing skin for evidence of inflammation Answer: 2, 3, 4, 5 Explanation: 1. Monitoring the hemoglobin level addresses an age-related change in the bone marrow that can lead to anemia, not blood pressure changes, in the older patient. 2. Because of age-related changes to the tunica media, blood pressure can decrease. This can lead to inadequate tissue perfusion and changes in the effects of medications. 3. Because of age-related changes to the tunica media, blood pressure can decrease. This can lead to inadequate tissue perfusion and pressure ulcers. 4. Because of age-related changes to the tunica media, blood pressure can decrease. This can lead to inadequate tissue perfusion and subsequent edema. 5. Because of age-related changes to the tunica media, blood pressure can decrease. This can lead to inadequate tissue perfusion and inflammation. Page Ref: 986 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.4 Differentiate considerations for assessing the cardiovascular and lymphatic systems of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

30 ..

32) Through genetic testing, parents learn that their adolescent child has long QT syndrome. What instruction regarding health protection should the nurse provide to this family? Select all that apply. 1. Avoid loud music. 2. Limit the intake of citrus fruits. 3. Avoid foods with extra sodium. 4. Practice caution when exercising. 5. Restrict the intake of dairy products. Answer: 1, 4 Explanation: 1. Long QT syndrome (LQTS) is an inherited genetic disorder that results from structural abnormalities of the sodium, potassium, and calcium channels in the heart, leading to dysrhythmias. This can result in unconsciousness and may cause sudden cardiac death in teenagers and young adults if they are exposed to stressors such as loud sounds. 2. There is no need for the patient to limit the intake of citrus fruits. 3. There is no need for the patient to avoid foods with extra sodium. 4. Long QT syndrome (LQTS) is an inherited genetic disorder that results from structural abnormalities of the sodium, potassium, and calcium channels in the heart, leading to dysrhythmias. This can result in unconsciousness and may cause sudden cardiac death in teenagers and young adults if they are exposed to stressors such as exercise. 5. There is no need for the patient to restrict the intake of dairy products. Page Ref: 968 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

31 ..

33) The nurse is preparing to assess a patient with Gaucher disease. What findings should the nurse expect when assessing this patient? Select all that apply. 1. Pain 2. Nausea 3. Fatigue 4. Jaundice 5. Hypotension Answer: 1, 3, 4 Explanation: 1. Gaucher disease is an inherited illness caused by the mutation of a gene that is responsible for an enzyme that breaks down a specific fat. When the fat is not broken down, it accumulates in the liver, spleen, and bone marrow, causing pain. 2. Nausea is not a manifestation of Gaucher disease. 3. Gaucher disease is an inherited illness caused by the mutation of a gene that is responsible for an enzyme that breaks down a specific fat. When the fat is not broken down, it accumulates in the liver, spleen, and bone marrow, causing fatigue. 4. Gaucher disease is an inherited illness caused by the mutation of a gene that is responsible for an enzyme that breaks down a specific fat. When the fat is not broken down, it accumulates in the liver, spleen, and bone marrow, causing jaundice. 5. Hypotension is not a manifestation of Gaucher disease. Page Ref: 968 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.2. Recognize the relationship of genetics and genomics to health, prevention, screening, diagnostics, prognostics, selection of treatment, and monitoring of treatment effectiveness, using a constructed pedigree from collected family history information as well as standardized symbols and terminology | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

32 ..

34) The nurse is participating in a health fair in a major metropolitan city park. For which community member should screening for thalassemia be suggested? Select all that apply. 1. 21-year-old male from Hong Kong 2. 55-year-old female who recently visited India 3. 32-year-old male who emigrated from Nigeria 4. 45-year-old female whose mother is from Italy 5. 68-year-old female returning from a trip to Croatia Answer: 1, 3, 4 Explanation: 1. Thalassemia, an inherited disease of faulty hemoglobin synthesis, is more often found in descendants of people living in Asia. Hong Kong is in Asia. 2. Thalassemia is not a communicable disease. Visiting India does not increase the person's risk of developing this disorder. 3. Thalassemia, an inherited disease of faulty hemoglobin synthesis, is more often found in descendants of people living in Africa. Nigeria is in Africa. 4. Thalassemia, an inherited disease of faulty hemoglobin synthesis, is more often found in descendants of people living near the Mediterranean Sea. Italy is near the Mediterranean Sea. 5. Thalassemia is not a communicable disease. Visiting Croatia does not increase the person's risk of developing this disorder. Page Ref: 968 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

33 ..

35) A patient has a genetic history of disorders. The nurse decides to include in the plan of care measures to protect the patient's cardiovascular health. What finding supported the nurse's clinical decision making? Select all that apply. 1. The patient's sister developed high cholesterol at age 32. 2. The patient's father had a myocardial infarction at age 50. 3. The patient's brother broke a leg while skiing in the winter. 4. The patient's uncle has cirrhosis of the liver and pancreatitis. 5. The patient's mother was diagnosed with high blood pressure at age 45. Answer: 1, 2, 5 Explanation: 1. When conducting a health assessment interview and physical assessment, it is important for the nurse to consider genetic influences on the health of the adult. The nurse should ask about family members with health problems affecting the cardiovascular system, such as high cholesterol levels. 2. When conducting a health assessment interview and physical assessment, it is important for the nurse to consider genetic influences on the health of the adult. The nurse should ask about family members with health problems affecting the cardiovascular system, such as early-onset CAD. 3. Having a brother with a broken leg from an accident is not a genetic influence on the patient's cardiovascular health. 4. Having an uncle with cirrhosis of the liver and pancreatitis is not a genetic influence on the patient's cardiovascular health. 5. When conducting a health assessment interview and physical assessment, it is important for the nurse to consider genetic influences on the health of the adult. The nurse should ask about family members with health problems affecting the cardiovascular system, such as high BP. Page Ref: 968 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.2. Conduct a health history, including environmental exposure and a family history that recognizes genetic risks, to identify current and future health problems | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

34 ..

36) While conducting a physical assessment the nurse detects atrophic changes on a patient's lower extremities. What physical finding did the nurse assess in this patient? Select all that apply. 1. Thick toenails 2. Skin ulcerations 3. Dilated leg veins 4. Skin discolorations 5. Absence of hair on the lower legs Answer: 1, 2, 4, 5 Explanation: 1. Atrophic changes are changes in the size or activity of body tissues resulting from pathology or injury. Reduced blood flow and oxygenation of the lower extremities often cause atrophic changes, including thick toenails. 2. Atrophic changes are changes in the size or activity of body tissues resulting from pathology or injury. Reduced blood flow and oxygenation of the lower extremities often cause atrophic changes, including ulcerations. 3. Dilated leg veins are related to varicose veins. 4. Atrophic changes are changes in the size or activity of body tissues resulting from pathology or injury. Reduced blood flow and oxygenation of the lower extremities often cause atrophic changes, including changes in pigmentation. 5. Atrophic changes are changes in the size or activity of body tissues resulting from pathology or injury. Reduced blood flow and oxygenation of the lower extremities often cause atrophic changes, including loss of hair. Page Ref: 973 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

35 ..

37) While assessing a patient's lymph nodes, the nurse suspects that the patient has a malignancy. What did the nurse assess to make this clinical decision? Select all that apply. 1. Painful nodes in the neck 2. Lymph nodes adhering to the chest wall 3. Rubbery lymph nodes in the femoral region 4. Hard, nodular lymph nodes in the axillary region 5. Warm lymph nodes along the upper chest Answer: 2, 3, 4 Explanation: 1. Malignant or metastatic nodes are usually nontender. 2. Malignant or metastatic nodes may be hard fixed to adjacent structures. 3. Malignant or metastatic nodes may be rubbery, indicating Hodgkin disease. 4. Malignant or metastatic nodes may be hard, indicating lymphoma. 5. Lymph nodes that are warm indicate infection. Page Ref: 977 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

36 ..

38) While conducting an abdominal assessment, the nurse percusses a dull sound below the tenth rib at the left midaxillary line. What should the nurse suspect is occurring with this patient? Select all that apply. 1. Cancer 2. Hemophilia 3. Viral infection 4. Blood dyscrasia 5. Bacterial infection Answer: 1, 3, 4 Explanation: 1. A palpable spleen in the left upper abdominal quadrant of an adult may indicate abnormal enlargement or splenomegaly and may be associated with cancer. 2. Hemophilia is a genetic illness associated with abnormalities in the clotting mechanism. 3. A palpable spleen in the left upper abdominal quadrant of an adult may indicate abnormal enlargement or splenomegaly and may be associated with a viral infection, such as mononucleosis. 4. A palpable spleen in the left upper abdominal quadrant of an adult may indicate abnormal enlargement or splenomegaly and may be associated with a blood dyscrasia. 5. A palpable spleen is not associated with bacterial infection. Page Ref: 977 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 29.3 Outline the components of the assessment of the cardiovascular and lymphatic systems including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the cardiovascular and lymphatic systems collected during assessment.

37 ..

39) The nurse is discussing arterial circulation with a group of new colleagues. Which should the nurse explain is a factor that determines peripheral vascular resistance (PVR)? Select all that apply. 1. Blood pressure 2. Blood viscosity 3. Chemoreceptors 4. Length of the vessel 5. Diameter of the vessel Answer: 2, 4, 5 Explanation: 1. Blood pressure (BP) is the force exerted against the walls of the arteries by the blood as it is pumped from the heart. 2. PVR is determined by blood viscosity. The greater the viscosity, or thickness, of the blood, the greater its resistance to moving and flowing. 3. Chemoreceptors affect arterial blood pressure. 4. PVR is determined by the length of the vessel. The longer the vessel, the greater the resistance to blood flow. 5. PVR is determined by the diameter of the vessel. The smaller the diameter of a vessel, the greater the friction against the walls of the vessel and, thus, the greater the impedance to blood flow. Page Ref: 961 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.2 Describe the anatomy, physiology, and functions of the peripheral vascular system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

38 ..

40) A patient with lower extremity edema asks why fluid accumulates in the feet. What should the nurse explain about the lymphatic system? Select all that apply. 1. Lymph vessels return the fluid to the heart. 2. Lymph vessels return lymph fluid through the arterial system. 3. Lymph vessels operate through a low-pressure system without a pump. 4. Lymph vessels transport fluid through the contraction of smooth muscle. 5. Lymph vessels collect excess fluid that leaks from the cardiovascular system. Answer: 1, 3, 4, 5 Explanation: 1. Lymph vessels return fluid that is leaked back to the heart. 2. Lymph vessels return lymph fluid through the lymphatic ducts that empty into subclavian veins. 3. Lymphatics are a low-pressure system without a pump. 4. The transport of lymph fluid depends on the rhythmic contraction of smooth muscle. 5. The lymphatic vessels collect and drain excess tissue fluid that leaks from the cardiovascular system. Page Ref: 963 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.2 Describe the anatomy, physiology, and functions of the peripheral vascular system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the cardiovascular and lymphatic systems.

39 ..

41) A patient with a blood pressure of 124/82 mmHg is prescribed lifestyle modifications. What should the nurse instruct to help reduce this patient's blood pressure? Select all that apply. 1. Stop smoking. 2. Reduce sodium intake. 3. Lose weight if overweight. 4. Engage in aerobic exercise for 30 minutes 4 days a week. 5. Limit alcohol intake to no more than 2 oz. of ethanol per day. Answer: 1, 2, 3 Explanation: 1. Lifestyle modifications for hypertension include smoking cessation. 2. Lifestyle modifications for hypertension include reducing sodium intake. 3. Lifestyle modifications for hypertension include losing weight if overweight. 4. Lifestyle modifications for hypertension include engaging in aerobic exercise for 30 minutes most days of the week. 5. Lifestyle modifications for hypertension include limiting alcohol intake to no more than 1 oz of ethanol, and ½ oz for women and lighter-weight people per day. Page Ref: 989 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.5 Summarize topics that nurses teach to promote cardiovascular and lymphatic health across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

40 ..

42) A patient with hypertension is prescribed the Dietary Approaches to Stop Hypertension (DASH) diet. What should the nurse teach the patient about this eating plan? Select all that apply. 1. Limit grains to six servings per day. 2. Eat four to five servings of fruit per day. 3. Eat two to three servings of fats and oils per day. 4. Limit sweets to five low-fat servings per week. 5. Limit meat to two or fewer 3 oz servings per day. Answer: 2, 3, 4, 5 Explanation: 1. On the DASH diet, seven to eight servings of grains should be consumed per day. 2. On the DASH diet, four to five servings of fruit should be consumed per day. 3. On the DASH diet, two to three servings of fats and oils should be consumed each day. 4. On the DASH diet, sweets should be limited to five low-fat servings per week. 5. On the DASH diet, meat should be limited to two or fewer 3 oz. servings per day. Page Ref: 989 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 29.5 Summarize topics that nurses teach to promote cardiovascular and lymphatic health across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the cardiovascular and lymphatic systems collected during assessment and health promotion activities to support the health of these body systems.

41 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 30 Nursing Care of Patients with Coronary Heart Disease 1) The nurse is preparing a teaching tool about coronary heart disease risk factors. Which information should the nurse include about modifiable risk factors? Select all that apply. 1. Hypertension 2. Diabetes mellitus 3. Obesity 4. Age 5. Heredity Answer: 1, 2, 3 Explanation: 1. A person can make a choice to modify hypertension by controlling it through medications, weight control, diet, and exercise. 2. A person can make a choice to modify diabetes mellitus by controlling it through medications, weight control, diet, and exercise. 3. A person can make a choice to modify obesity by controlling it through medications, weight control, diet, and exercise. 4. Hereditary effects on coronary heart disease cannot be changed. 5. Aging effects on coronary heart disease cannot be changed. Page Ref: 1001 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

1 ..

2) A patient is experiencing chest pain. What diagnostic test should the nurse anticipate being prescribed for this patient to determine coronary artery status? 1. Coronary angiography 2. Stress electrocardiography 3. Echocardiography 4. Radionuclide testing Answer: 1 Explanation: 1. The gold standard for evaluating coronary arteries is coronary angiography. This test visualizes the coronary arteries to determine the presence of disease. 2. A stress electrocardiogram will probably not be done until the angiography is completed and analyzed. 3. An echocardiogram evaluates cardiac structure and function and not coronary arteries. 4. Radionuclide testing evaluates myocardial perfusion and left ventricular function but does not specifically focus on the coronary arteries. Page Ref: 1007 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

2 ..

3) Aspirin has been prescribed for a patient following a myocardial infarction. What should the nurse include when teaching about this drug? 1. Check with your healthcare provider before taking any herbal remedies. 2. Report any itching that develops after seven days of taking the drug. 3. Take at a different time of day than warfarin (Coumadin). 4. Do not skip any scheduled appointments to have blood drawn for labs. Answer: 1 Explanation: 1. Herbal remedies such as evening primrose oil, garlic, gingko biloba, or grapeseed extract can increase the effect of the aspirin. 2. Itching is not a common side effect of aspirin therapy. 3. Aspirin and warfarin (Coumadin) are not to be taken concurrently. 4. No laboratory appointments will be made just for aspirin therapy. Page Ref: 1013 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

3 ..

4) A patient recovering from coronary artery bypass graft (CABG) surgery has a heart rate of 120 bmp, blood pressure 90/50 mmHg, decreased urine output, decreased chest tube output, muffled heart sounds, and weak peripheral pulses. What action should the nurse take first? 1. Notify the physician immediately. 2. Recheck vital signs in 15 minutes. 3. Reposition the patient. 4. Increase the intravenous fluids. Answer: 1 Explanation: 1. The patient is exhibiting signs of cardiac tamponade. This is a medical emergency, and the physician must be notified immediately. 2. Delaying the response by waiting 15 minutes will be ineffective. 3. Repositioning the patient will be ineffective. 4. No change in intravenous fluids should be made until a physician order is given to do so. Page Ref: 1017 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

4 ..

5) A middle-aged female patient asks why she has not been prescribed a daily dose of aspirin when her spouse of the same age has been. What should the nurse explain is the most likely reason for this? 1. The benefit of aspirin in women under age 65 is not clear. 2. Aspirin is not recommended for women. 3. This must have been an oversight. 4. She has other medications that could interfere. Answer: 1 Explanation: 1. In women, the benefit of low-dose aspirin in reducing the risk for coronary heart disease is not clear prior to 65 years of age. 2. Aspirin is recommended for women over the age of 65. 3. This was not an oversight. 4. There is not enough information to determine whether the patient has other medications that could interfere with aspirin. Page Ref: 1004 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

5 ..

6) A patient recovering from a myocardial infarction asks if it is appropriate to use garlic and drink red wine. Which response should the nurse make? 1. "Discuss your idea with the physician to see what would benefit you." 2. "That sounds fine. See how they work." 3. "I wouldn't do that if I were you." 4. "You should also add ginkgo biloba for cardiovascular health." Answer: 1 Explanation: 1. Complementary therapies could be helpful. They should be added only after discussion with a healthcare provider who is familiar with the patient's history and current medication/allergy list. Interactions between herbal preparations and prescribed medications are common. 2. They should be added only after discussion with a healthcare provider who is familiar with the patient's history and current medication/allergy list. 3. Ignoring the comment or discouraging the patient would not be beneficial. 4. Recommending any other complementary therapies is beyond the scope of practice of the nurse. Page Ref: 1004 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

6 ..

7) The nurse instructs a patient about cardiac risk factors. For which laboratory test should the patient be instructed to increase the intake of foods with folic acid and the B vitamins? 1. Homocysteine 2. Creatinine 3. High density lipoprotein (HDL) 4. INR Answer: 1 Explanation: 1. Homocysteine levels are negatively correlated with serum folate and dietary folate intake; that is, increasing folate intake lowers homocysteine levels. 2. Creatinine level is not impacted by folic acid and B vitamins. 3. HDL level is not impacted by folic acid and B vitamins. 4. INR is a laboratory test that measures blood clotting function and is not impacted by folic acid or B vitamins. Page Ref: 1002 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

7 ..

8) A patient is experiencing chest pain. Which should the nurse expect to assess if this patient is experiencing an acute myocardial infarction? 1. Substernal pressure type pain, radiating down the left arm 2. Colic-like epigastric pain 3. Sharp, well-localized unilateral chest and left arm pain 4. Sharp, burning chest pain moving from place to place Answer: 1 Explanation: 1. The cardinal manifestation of acute coronary syndrome (ACS) is chest pain, usually substernal or epigastric. The pain often radiates to the shoulders, neck, jaw, or arm. 2. Cardiac chest pain is not usually described as colic-like, localized to a defined spot such as the epigastric area, or as a sharp pain. 3. Cardiac chest pain is not usually described as localized to a defined spot or as a sharp pain. 4. Cardiac chest pain is not usually described as a sharp pain. Page Ref: 1011 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

8 ..

9) The nurse is caring for a patient diagnosed with variant angina. What should this diagnosis indicate to the nurse? 1. Presence of coronary artery spasm 2. Associated with renal disease 3. Associated with pulmonary disease 4. Presence of a myocardial infarction Answer: 1 Explanation: 1. Prinzmetal (variant) angina is atypical angina that occurs unpredictably (unrelated to activity) and often at night. It is caused by coronary artery spasm with or without an atherosclerotic lesion. The exact mechanism of coronary artery spasm is unknown. 2. Prinzmetal angina does not occur due to renal disorders. 3. Prinzmetal angina does not occur due to a pulmonary disorder. 4. Prinzmetal angina is not specifically diagnostic for a myocardial infarction. Page Ref: 1006 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

9 ..

10) A patient enters the emergency department complaining of chest pain that is radiating down the left arm. The emergent treatment plan for this patient should include which nursing action? Select all that apply. 1. Morphine intravenously and oxygen 2. Aspirin 325 mg orally 3. Open heart surgery 4. Heparin drip at 100 units per hour 5. Insert indwelling urinary catheter Answer: 1, 2 Explanation: 1. Pain relief is vital in treating the patient with acute myocardial infarction (AMI). Pain stimulates the sympathetic nervous system, increasing the heart rate and blood pressure and, in turn, myocardial workload. Oxygen is administered by nasal cannula at 2 to 5 L/min to improve oxygenation of the myocardium and other tissues. 2. Aspirin, a platelet inhibitor, is now considered an essential part of AMI treatment. A 160- to 325-mg aspirin tablet is given by emergency personnel, with the instructions that it is to be chewed (for buccal absorption). 3. Open heart surgery may be indicated later. 4. Heparin is not part of the admission protocol. 5. A Foley catheter is not part of the admission protocol. Page Ref: 1024, 1026 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

10 ..

11) The nurse suspects that a patient experienced a transmural myocardial infarction. What electrocardiogram finding did the nurse use to make this clinical decision? 1. Q wave deepening 2. ST segment elevation 3. ST segment depression 4. P wave inversion Answer: 1 Explanation: 1. A significant Q wave develops with a transmural infarction, so this also may be called a Q-wave MI. 2. ST segment elevation represents myocardial ischemia, which is reversible by increasing the blood flow to the heart. 3. ST segment depression occurs when muscle ischemia involves only a portion of the heart wall. 4. P wave inversion represents a junctional pacemaker in the heart and is not related to changes that occur with a myocardial infarction. Page Ref: 1020 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

11 ..

12) A patient reports chest pain, nausea, and vomiting off and on for the last 4 days, which the patient interpreted as the flu. What laboratory test will provide information about acute cardiac damage for this patient? 1. Troponin I and T 2. Red blood cells 3. CK-MB 4. Homocysteine and platelets Answer: 1 Explanation: 1. The levels of troponin T begin to rise within 2‒4 hours after myocardial injury and remain elevated 10‒14 days. Levels of troponin I begin to increase in about 2‒4 hours after myocardial ischemia and peak at 24‒36 hours and remain elevated for 7‒10 days. 2. Red blood cells are unaffected by acute cardiac damage. 3. The CK-MB rises within 4‒8 hours after the MI, peaks within 18‒24 hours and levels return to normal 2‒3 days following the infarction. This patient would most likely have normal values 4 days out from the onset of symptoms. 4. Homocysteine does not change with acute cardiac damage. Platelets are unaffected by acute cardiac damage. Page Ref: 1012 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

12 ..

13) Fifteen hours after admission, a patient's CK-MB level is markedly increased. What should this indicate to the treatment team? 1. Cellular necrosis of myocardial tissue has occurred. 2. Lactic acid is present. 3. Thrombolytic therapy is indicated. 4. Cardiac function has returned to normal. Answer: 1 Explanation: 1. CK-MB is the intracellular enzyme that is released when cell damage and death occur. CK-MB becomes elevated when myocardial cell death has occurred. 2. The pH is the indicator of lactic acid buildup. 3. Thrombolytic therapy is indicated within the first 12 hours after symptoms develop; thus, it is too late for this intervention. 4. Cardiac function has not returned to normal. Page Ref: 1012 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

13 ..

14) The nurse is caring for a patient experiencing acute myocardial infarction. What electrocardiogram change should the nurse expect for this patient's health problem? 1. ST-segment elevation 2. Loss of P waves 3. Bradycardia 4. Widening of the QRS complex Answer: 1 Explanation: 1. The electrocardiogram reflects changes in conduction due to myocardial ischemia and necrosis. Classic ECG changes seen in acute myocardial infarction include STsegment elevation. 2. Loss of P waves occurs with atrial flutter and fibrillation. 3. Bradycardia can be a normal or abnormal rhythm. It is not specifically associated with an acute myocardial infarction. 4. Widening of the QRS complex occurs with bundle branch block. It is not specifically associated with an acute myocardial infarction. Page Ref: 1012 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

14 ..

15) The nurse is caring for a patient recovering from fibrinolytic therapy. For which common complication should the nurse focus care for this patient? 1. Bleeding 2. Hypotension 3. Lethargy 4. Heart block Answer: 1 Explanation: 1. Hemorrhage or bleeding is the most common complication; it can be lifethreatening. 2. Hypotension can occur, but it is not the most common complication. 3. Lethargy is not associated with fibrinolytic therapy. 4. Heart block is not associated with fibrinolytic therapy. Page Ref: 1025 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

15 ..

16) Upon auscultating the chest of an older patient who recently experienced a myocardial infarction (MI), the nurse hears an S3 and lung crackles. Because of these findings, the nurse should assess for what other condition? 1. Heart failure 2. Extension of the MI 3. Renal failure 4. Liver failure Answer: 1 Explanation: 1. S3 and lung crackles are indications of heart failure. 2. Manifestations of MI extension include chest pain and a return of positive laboratory finding (CK-MB and troponin). 3. Renal failure is a late complication of heart failure and is not manifested with an S 3 and crackles. 4. Liver failure is not manifested with an S3 and crackles. Page Ref: 1017 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

16 ..

17) A patient recovering from cardiovascular surgery has a chest tube output of 110 mL/hr. What should the nurse do? Select all that apply. 1. Report to the surgeon. 2. Check the hemoglobin and hematocrit. 3. Administer a blood transfusion. 4. Notify the family. 5. Strip and vent the chest tube. Answer: 1, 2 Explanation: 1. Chest tube drainage greater than 70 mL/hr indicates hemorrhage and may necessitate a return to surgery. The surgeon should be notified of this chest tube draining amount. 2. A drop in hemoglobin and hematocrit may indicate hemorrhage that is not otherwise obvious. 3. The patient needs to be assessed along with the laboratory data before it is determined if a blood transfusion is necessary. 4. There is no need to notify family until the patient has been assessed. It may not be of significance. 5. Stripping and venting of the chest tube is not necessary because of the use of a closed drainage system. Page Ref: 1017 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

17 ..

18) The family of a patient who experienced a stroke after percutaneous coronary revascularization asks the nurse what caused the stroke to occur. How should the nurse respond to the family? 1. "A stroke could have been caused by clot particles from the procedure." 2. "Stroke is usually caused by ruptured plaque inside the coronary artery." 3. "Stroke is caused by heart failure." 4. "No one knows what causes strokes." Answer: 1 Explanation: 1. After percutaneous coronary revascularization clot particles can migrate, leading to a stroke. 2. Plaque inside a coronary artery would travel downstream and lodge in a smaller vessel in the heart. 3. Heart failure does not cause a stroke. 4. Stating that no one knows what causes strokes is not a true statement; blood clots and ruptured vessels cause strokes. Page Ref: 1015 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

18 ..

19) The nurse is participating in a screening program for coronary heart disease (CHD). For which information should the nurse evaluate a patient for CHD? Select all that apply. 1. Diabetes 2. Hyperlipidemia 3. Positive family history 4. A premenopausal woman 5. Hypotension Answer: 1, 2, 3 Explanation: 1. Diabetes is a disease condition that contributes to coronary heart disease (CHD). 2. Hyperlipidemia is a disease condition that contributes to heart disease (CHD). 3. Positive family history in some cases is considered a nonmodifiable risk factor for heart disease (CHD). 4. Premenopausal women are not considered at an increased risk for heart disease (CHD). 5. Hypotension is not associated with development of heart disease (CHD). Page Ref: 997 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

19 ..

20) The nurse is conducting teaching about risk factor management for cardiovascular disease (CVD) at a senior center. What is the most important information for the nurse to include? 1. Stop smoking. 2. Eat in moderation. 3. Exercise when able. 4. Reduce saturated fats in the diet. Answer: 1 Explanation: 1. Cigarette smoking is a major independent risk factor for coronary heart disease. 2. The problems associated with diet management are not as significant as smoking. 3. Exercise is important but not as significant a factor as smoking. 4. Diet management is important but not as significant a factor as smoking. Page Ref: 1001 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

20 ..

21) The nurse is preparing medications for a patient with hyperlipidemia. What information should the nurse consider when administering these medications? 1. Such medications include the statins, which act by lowering LDL levels. 2. These medications act by increasing the LDL levels and decreasing the HDL levels. 3. These medications do not include angiotensin-converting enzyme (ACE) inhibitors. 4. Such medications include bile acid sequestrants as first-line drugs to lower cholesterol levels. Answer: 1 Explanation: 1. The statin drugs specifically lower LDL. 2. Hyperlipidemia drugs are meant to lower LDL and raise HDL, not the opposite. 3. The use of angiotensin-converting enzyme (ACE) inhibitors depends upon the patient's health status. 4. Bile acid sequestrant drugs are not first-line drugs but may be added to statins when combination treatment is needed. Page Ref: 1002 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

21 ..

22) A patient is prescribed atorvastatin (Lipitor). For which adverse effect should the nurse monitor this patient? 1. Liver enzyme alteration 2. Blood glucose and uric acid level alteration 3. Renal function alteration 4. Sudden back pain and constipation Answer: 1 Explanation: 1. The nurse should be observing laboratory work for the current cholesterol level and to ensure that liver enzymes remain normal. 2. Blood glucose and uric acid level are generally not associated with the use of this drug. 3. Renal function alteration is generally not associated with the use of this drug. 4. Constipation and sudden back pain are generally not associated with the use of this drug. Page Ref: 1003 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

22 ..

23) The nurse has completed teaching related to dietary management of coronary heart disease (CHD). Which patient statement indicates that teaching has been effective? 1. "I can lower my trans fatty acids by switching to the soft margarines and vegetable spreads." 2. "I will watch my fiber intake so I don't get too much." 3. "Well, I'll just have to go buy some of that coconut oil to cook with." 4. "Drinking a couple of glasses of milk each day will give me better protein." Answer: 1 Explanation: 1. Trans fatty acids behave like saturated fats and are found in solid vegetable fats (margarine, shortening) and stick butter. Therefore, the use of soft margarines and vegetable spreads is recommended for managing CHD. 2. Other dietary recommendations include increasing soluble and insoluble fiber in the diet. 3. High proportions of saturated fats are found in coconut oil and red meats. 4. High proportions of saturated fats are found in whole-milk products. Page Ref: 1001 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

23 ..

24) A middle-aged obese male patient with elevated triglycerides and a history of smoking two packs of cigarettes a day for 20 years asks about the risk for coronary artery disease. What information should the nurse provide? 1. He is at risk for coronary artery disease. 2. He is not at risk for coronary artery disease. 3. He has nothing but nonmodifiable risk factors for coronary artery disease. 4. He has nothing but modifiable risk factors for coronary artery disease. Answer: 1 Explanation: 1. Age is a nonmodifiable risk factor, while obesity, elevated triglycerides, and smoking are modifiable risk factors. Together, the risk factors place the patient at higher risk to develop coronary artery disease. 2. Age is a nonmodifiable risk factor, while obesity, elevated triglycerides, and smoking are modifiable risk factors. Together, the risk factors place the patient at higher risk to develop coronary artery disease. 3. Age is a nonmodifiable risk factor, while obesity, elevated triglycerides, and smoking are modifiable risk factors. Together, the risk factors place the patient at higher risk to develop coronary artery disease. 4. Age is a nonmodifiable risk factor, while obesity, elevated triglycerides, and smoking are modifiable risk factors. Together, the risk factors place the patient at higher risk to develop coronary artery disease. Page Ref: 1000 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

24 ..

25) The nurse is caring for an adult patient who is admitted with chest pain that began four hours ago. Which test will be most specific in identifying acute heart damage? 1. Troponin 2. CK 3. CK-MB 4. Cholesterol Answer: 1 Explanation: 1. Troponin is primarily located in cardiac muscle and can indicate myocardial infarction or unstable angina. Troponin elevates at 2‒4 hours after myocardial infarction. 2. CK and CK-MB will elevate with myocardial damage, but will take longer to rise and are not as specific as troponin. 3. CK and CK-MB will elevate with myocardial damage, but will take longer to rise and are not as specific as troponin. 4. Cholesterol level is not helpful in diagnosis of myocardial damage. Page Ref: 1012 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

25 ..

26) The nurse is caring for a patient with ventricular tachycardia. Which care should the nurse prepare to provide to this patient? Select all that apply. 1. Immediate assessment and probable emergency intervention by the nurse 2. Cardioversion, if sustained and symptomatic 3. Administration of a potassium channel blocker 4. Close observation for one hour prior to calling the physician 5. Defibrillation to convert the rhythm in the awake patient Answer: 1, 2, 3 Explanation: 1. Sustained ventricular tachycardia is a medical emergency that requires immediate intervention, particularly in patients with cardiac disease. 2. Treatment for ventricular tachycardia includes cardioversion. 3. Class III antidysrhythmic medications (potassium channel blockers) are typically administered. 4. Observation prior to calling a physician is not an appropriate action when a potentially lifethreatening rhythm is identified. 5. Defibrillation is only conducted in ventricular tachycardia when the patient is pulseless; otherwise, time is taken to synchronize for cardioversion. Page Ref: 1034 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

26 ..

27) A patient has a junctional escape rhythm. Which action should the nurse make a priority? 1. Assess the patient for symptoms associated with this rhythm. 2. Contact the physician immediately for emergency orders. 3. Eliminate caffeine from the diet. 4. Prepare for a pacemaker insertion. Answer: 1 Explanation: 1. Junctional escape rhythms may be monitored if the patient is not symptomatic. It is most important to assess the patient to see how they are affected by the rhythm. 2. Calling the physician to report the rhythm may be appropriate if the patient is symptomatic. 3. Eliminating caffeine is not an appropriate action for this patient with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given. 4. Preparing for a pacemaker insertion is not an appropriate action for this patient with a junctional escape rhythm. No indication of symptoms relating to the rhythm was given. Page Ref: 1034 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

27 ..

28) The nurse is instructing a patient on nitroglycerin tablets prescribed to treat angina. Which statement should be included in the nurse's instructions? Select all that apply. 1. "Take a second dose if the angina is not relieved within five minutes." 2. "The drug should remain in this brown bottle since it is sensitive to light." 3. "Store this medication in your bathroom medicine cabinet so it is readily available to you." 4. "Eating or drinking will not interfere when taking the medication." 5. "Call your doctor immediately if you develop a headache when taking this drug." Answer: 1, 2 Explanation: 1. A second dose of nitrates is recommended within five minutes if the first dose does not relieve the angina. 2. Sublingual nitrates should not be removed from their original amber bottle since it protects the medication from light. 3. The medication should be stored in a dry location and not placed in the bathroom medicine cabinet because moisture affects nitrates. 4. This medication is taken sublingually; therefore, eating and drinking will interfere with absorption. 5. A transient headache may occur when taking this medication and will diminish over time. Page Ref: 1008 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

28 ..

29) Sinus bradycardia with a rate 56 beats per minute is identified in a sleeping patient on telemetry. Which action should the nurse take first? 1. Awaken the patient and see how the heart rate responds. 2. Call the physician and report this dysrhythmia. 3. Check the medication administration record and see if there is a PRN medication that will improve this rhythm. 4. Call for an immediate 12-lead electrocardiogram (ECG). Answer: 1 Explanation: 1. The priority is to awaken the patient to determine how the heart rate is affected with activity as it normally should increase. The patient should be evaluated to determine how the dysrhythmia is affecting heart function. Many patients who are asymptomatic while in sinus bradycardia can be observed and require no further intervention. Common reasons for sinus bradycardia for the nurse to consider include athletic conditioning, sleep, or a conduction disorder. 2. Notifying the physician without first assessing the patient's response would not be appropriate. 3. Checking the medication administration is not the priority nursing action. 4. Ordering an ECG requires a physician's prescription. Page Ref: 1036 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

29 ..

30) A patient is in sinus tachycardia. Which nursing interventions are appropriate? Select all that apply. 1. Observe the patient for effects on cardiac function. 2. Administer two tablets of acetaminophen (Tylenol) per physician prescription if an elevated temperature is present. 3. Administer normal saline 0.9% IV at the prescribed rate of 200 mL per hour if hypovolemia is suspected as the cause. 4. Give pain medications as prescribed if pain is present. 5. Give atropine per physician prescription to slow the heart rate. Answer: 1, 2, 3, 4 Explanation: 1. Appropriate nursing interventions for the patient in sinus tachycardia include observing the patient for effects on cardiac function. 2. Appropriate nursing interventions for the patient in sinus tachycardia include treating fever. 3. Appropriate nursing interventions for the patient in sinus tachycardia include treating hypovolemia. 4. Appropriate nursing interventions for the patient in sinus tachycardia include treating pain. 5. Atropine acts to increase heart rate and may be a cause of sinus tachycardia. Page Ref: 1033, 1047 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

30 ..

31) A patient with a pacemaker has one pacing spike before every QRS complex and the rhythm does not change with rest or activity. For which type of pacemaker should the nurse plan care for this patient? 1. Asynchronous pacing 2. Demand pacing 3. Dual-chamber pacing 4. Atrial single-chamber pacing Answer: 1 Explanation: 1. Asynchronous pacing delivers a pacing stimulus at a set rate regardless of intrinsic cardiac activity. 2. A demand pacemaker spike varies with the heart rate. 3. A dual-chamber pacer normally produces two pacing spikes, one before the P wave and one before the QRS. 4. An atrial pacer would produce a spike, normally with a P wave that follows it prior to the QRS. Page Ref: 1043 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

31 ..

32) A patient on continuous cardiac monitoring is in no apparent distress, sitting in the chair and eating. Which action should the nurse take? Select all that apply. 1. Confirm that lead wires are properly connected. 2. Assess placement of electrodes. 3. Remove and reapply new electrodes if nonadherent. 4. Assess skin sites and move an electrode if the skin appears irritated. 5. Call for assistance. Answer: 1, 2, 3, 4 Explanation: 1. Nursing actions include assessing lead wire connections. 2. Nursing actions include assessing placement of electrodes. 3. Nursing actions include changing electrodes every 24 to 48 hours or removing and reapplying electrodes that are dislodged or nonadherent. 4. Nursing actions include assessing and documenting skin condition under the pads and moving pads to alternate sites to avoid skin irritation. 5. Since the patient is in no apparent distress, assistance is not required. Page Ref: 1047 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

32 ..

33) A patient is experiencing nausea, loss of appetite, blurred and double vision, green yellow halos, vomiting and "feeling uneasy." What drug toxicity should the nurse suspect is occurring with this patient? 1. Digoxin 2. Lidocaine 3. Amiodarone 4. Procainamide Answer: 1 Explanation: 1. Classic symptoms of digoxin toxicity include anorexia, nausea, vomiting, blurred or double vision, yellow green halos, and new-onset dysrhythmias. 2. Lidocaine toxicity is manifested by changes in neurologic status. 3. Amiodarone toxicity is manifested by altered hepatic function, pulmonary fibrosis, and photosensitivity. 4. Procainamide toxicity is manifested by flu-like symptoms, skin rash, and signs of heart failure. Page Ref: 1041 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

33 ..

34) The nurse is caring for a patient with premature ventricular contractions (PVCs). What should the nurse keep in mind about this heart rhythm? 1. PVCs are insignificant in people with no history of heart disease. 2. PVCs typically have no pattern. 3. The frequency of PVCs is not associated with specific events. 4. Their incidence and significance have no relevance to the patient having had a myocardial infarction. Answer: 1 Explanation: 1. PVCs often have no significance in people without history of heart disease. 2. PVCs may be isolated or occur in specific patterns. 3. PVCs may be triggered by anxiety or stress; tobacco, alcohol, or caffeine use; hypoxia, acidosis, and electrolyte imbalances; sympathomimetic drugs; and coronary heart disease. 4. PVCs may be associated with an increased risk for lethal dysrhythmias and their incidence and significance are greatest after myocardial infarction. Page Ref: 1037 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with coronary heart disease.

34 ..

35) A patient is recovering from implantable cardioverter-defibrillator (ICD) insertion. Which teaching should the nurse provide to the patient during discharge? 1. "If a family member is in direct contact with you when the ICD discharges, he or she may experience a shock or tingling sensation." 2. "You can activate the ICD whenever you feel a change in your heart rhythm." 3. "The batteries of the ICD won't need to be replaced if the ICD never shocks the heart." 4. "There should be no discomfort if the ICD discharges, and you probably won't notice it." Answer: 1 Explanation: 1. Family members may receive a shock or tingling sensation when in direct contact with an individual when their ICD discharges. 2. The ICD is programmed to automatically activate when detecting a potentially lethal cardiac rhythm and cannot be activated by the patient. 3. Batteries must be surgically replaced every five years or following manufacturer's instructions. 4. Some patients experience significant discomfort with ICD discharge. Page Ref: 1046 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

35 ..

36) The nurse is preparing a presentation on coronary heart disease (CHD) for a community women's club. Which statement should the nurse include in the presentation? Select all that apply. 1. The epigastric pain and nausea experienced with a heart attack are often attributed to heartburn. 2. Common symptoms of myocardial infarction (MI) include shortness of breath and fatigue. 3. Women are more likely to have an unrecognized myocardial infarction. 4. Weakness of the legs and back often precede a heart attack. 5. The mortality rate of young women having an MI is 50% lower than that of men. Answer: 1, 2, 3 Explanation: 1. Common symptoms of MI in women include epigastric pain or nausea, which is blamed on heartburn, shortness of breath, fatigue, and weakness of the shoulders and upper arms. 2. Common symptoms of MI in women include epigastric pain or nausea, which is blamed on heartburn, shortness of breath, fatigue, and weakness of the shoulders and upper arms. 3. "Silent" or unrecognized heart attack occurs more frequently in women than men. 4. Weakness of the legs and back does not precede a heart attack. 5. The mortality rate of young women having an MI is twice that of men. Page Ref: 1021 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with coronary heart disease.

36 ..

37) A patient with coronary heart disease (CHD) is prescribed propranolol (Inderal). For which information in the patient's history should the nurse question this prescription? 1. Asthma and chronic obstructive pulmonary disease (COPD) 2. Taking antioxidants 3. Taking simvastatin (Zocor) 4. Bleeding disorders Answer: 1 Explanation: 1. Class II beta-blockers such as propranolol are used to reduce heart rate and myocardial contractility and in the treatment of supraventricular tachycardia. These drugs may cause bronchospasm and are contraindicated for patients with asthma, chronic obstructive pulmonary disease (COPD), or other restrictive or obstructive lung diseases. 2. Antioxidants may be taken concurrently with propranolol. 3. Simvastatin may be taken concurrently with propranolol. 4. Bleeding disorders are not associated with propranolol use. Page Ref: 1008 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

37 ..

38) A patient identified as being at risk for coronary heart disease does not understand why exercise is important. What should the nurse explain to this patient? Select all that apply. 1. Exercise decreases blood pressure.

2. Exercise increases oxygen to the heart. 3. Exercise potentiates platelet aggregation. 4. Exercise decreases the workload of the heart. 5. Exercise improves the electrical ability of the heart. Answer: 1, 2, 4, 5 Explanation: 1. Cardiovascular benefits of exercise include decreasing blood pressure. 2. Cardiovascular benefits of exercise include increased availability of oxygen to the heart muscle. 3. Cardiovascular benefits of exercise include decreasing platelet aggregation. 4. Cardiovascular benefits of exercise include decreasing oxygen demand and cardiac workload. 5. Cardiovascular benefits of exercise include increasing cardiac electrical stability. Page Ref: 1002, 1005 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

38 ..

39) A patient with a high risk for coronary heart disease is prescribed a 1750-kcal diet in which 55% of the diet is to be carbohydrates and 20% fat. How many calories should the nurse instruct the patient consume as protein each day? Record your answer rounding up to the nearest whole number. Answer: 438 kcal Explanation: If the patient is to consume 55% of the diet as carbohydrates and 20% as fat that means the patient is to consume 25% of the total calories as protein. To determine protein calories, the nurse should multiply the total number of calories per day by 25%, or 1750 × .25 = 437.5 or 438 kcal. Page Ref: 1004 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

39 ..

40) A patient with coronary heart disease is prescribed niacin (Nicobid). What should the nurse instruct the patient about this medication? Select all that apply. 1. Take with meals and a cold beverage. 2. Take with prescribed statin medication. 3. Keep routine appointments for blood work. 4. Report facial flushing to the healthcare provider. 5. Drink 4 ounces of alcohol if facial flushing occurs. Answer: 1, 2, 3 Explanation: 1. The medication should be taken with meals and accompanied by a cold beverage to minimize GI effects. 2. Because the doses required to achieve significant cholesterol-lowering effects are associated with multiple side effects, nicotinic acid generally is used in combination therapy, particularly with the statin drugs. 3. Because this medication can have adverse effects, routine monitoring of blood glucose, uric acid levels, and liver function tests should be done during treatment. 4. Flushing of face, neck, and ears may occur within 2 hours following dose; these effects generally subside as treatment continues. 5. Alcohol use during nicotinic acid therapy may worsen facial flushing. Page Ref: 1003 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 30.1 Describe the pathophysiology and manifestations of disorders of myocardial perfusion, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with coronary heart disease.

40 ..

41) A patient is experiencing supraventricular tachycardia. Which medications should the nurse prepare to administer to this patient? Select all that apply. 1. Verapamil (Calan) 2. Diltiazem (Cardizem) 3. Amlodipine (Norvasc) 4. Propafenone (Rythmol) 5. Adenosine (Adenocard) Answer: 1, 2, 3, 5 Explanation: 1. Calcium channel blockers decrease automaticity and AV nodal conduction. They are used to manage supraventricular tachycardia. These medications include verapamil (Calan). 2. Calcium channel blockers decrease automaticity and AV nodal conduction. They are used to manage supraventricular tachycardia. These medications include diltiazem (Cardizem). 3. Calcium channel blockers decrease automaticity and AV nodal conduction. They are used to manage supraventricular tachycardia. These medications include amlodipine (Norvasc). 4. Propafenone (Rythmol) is used to reduce or eliminate tachydysthymias associated with reentry. 5. Adenosine (Adenocard) decreases conduction through the AV node and is used to treat supraventricular tachycardia. Page Ref: 1041 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 30.2 Describe the pathophysiology and manifestations of cardiac dysrhythmias, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with coronary heart disease.

41 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 31 Nursing Care of Patients with Cardiac Disorders 1) The nurse is assessing a patient with chronic heart failure. Which abnormal chest sound should the nurse expect to auscultate? 1. Expiratory wheezes 2. Friction rub 3. Harsh vesicular sounds 4. Crackles Answer: 4 Explanation: 1. Expiratory wheezes are not associated with chronic heart failure. 2. Friction rub is not associated with chronic heart failure. 3. Harsh vesicular sounds are not associated with chronic heart failure. 4. Fluid accumulates in the alveolar spaces in left-sided heart failure. This fluid causes the sound of crackles at the end of inspiration. Page Ref: 1060 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

1 ..

2) The nurse is caring for a chronic heart failure patient with left-sided failure. Which documentation should the nurse expect to see in the medical record after this patient has a cardiac catheterization? 1. "Pressures in the left ventricle and atrium are increased." 2. "Pressures in the left ventricle and atrium are decreased." 3. "Pressures in the right ventricle and atrium match the ventricle pressures." 4. "Pressures in the right ventricle reflect functioning of all heart chambers." Answer: 1 Explanation: 1. As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume. 2. As the heart loses its ability to eject blood effectively from the left ventricle upon contraction, blood is retained in the left ventricle after systole and the chamber pressure rises due to the added blood volume. 3. This patient is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. 4. This patient is in left-sided heart failure, so pressure is higher in the left side of the heart, not the right side. Page Ref: 1060 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation/Communication and Documentation Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

2 ..

3) The nurse is caring for a patient with heart failure. What should the nurse expect when assessing this patient? 1. S1, S2, and flat neck veins 2. S3 and distended neck veins 3. S2 heard the loudest and followed by S1 4. S4 and flat neck veins Answer: 2 Explanation: 1. S1 and S2 are normal heart sounds; flat neck veins are considered a normal finding. 2. The abnormal S3 sound is reflective of the heart's attempts to fill an already distended ventricle, and the neck veins distend because of the increased venous pressure. Most patients have elements of both right- and left-sided heart failure. 3. S1 and S2 sounds may be diminished in the heart failure patient and do not vary in intensity. 4. S4 (gallop) may be present, but neck veins would be distended. Page Ref: 1062 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

3 ..

4) The nurse is obtaining the health history of a patient who is being assessed for possible heart failure (HF). Which patient statement should the nurse identify as being associated with this health problem? 1. "I break out in a cold sweat when I eat a large meal." 2. "I am sleepy after I eat lunch every day." 3. "I have to prop myself up on three pillows to sleep at night. Otherwise I can't breathe." 4. "I feel better with my legs down when I sit in my favorite chair." Answer: 3 Explanation: 1. Diaphoresis is not related to a diagnosis of HF. 2. Sleepiness after meals is not related to a diagnosis of HF. 3. Needing to prop oneself up with pillows at night to breathe describes orthopnea, which is consistent with heart failure (HF). HF produces a volume excess, congestion in the lungs, and dyspnea when the patient attempts to lie down. 4. The effects of leg position are not related to a diagnosis of HF. Page Ref: 1060 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

4 ..

5) A patient is admitted with acute heart failure. Which health problem most likely caused this new condition? Select all that apply. 1. Cardiomyopathy 2. Heart valve disease 3. Coronary heart disease (CHD) 4. Massive infarction (MI) 5. Myocardial injury Answer: 4, 5 Explanation: 1. Cardiomyopathy is associated with chronic heart failure. 2. Valve disease is associated with chronic heart failure. 3. Coronary heart disease (CHD) is associated with chronic heart failure. 4. Acute failure is the abrupt onset of a myocardial injury (such as a massive MI) resulting in suddenly reduced cardiac function and signs of reduced cardiac output. 5. Acute failure is the abrupt onset of a myocardial injury (such as a massive MI) resulting in suddenly reduced cardiac function and signs of reduced cardiac output. Page Ref: 1061 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

5 ..

6) Blood tests are prescribed for a patient with suspected heart failure (HF). Which test result should the nurse review to support this medical diagnosis? 1. Liver function 2. Urinalysis and blood urea nitrogen (BUN) 3. Brain natriuretic peptide (BNF) 4. Serum electrolytes Answer: 3 Explanation: 1. Liver function tests are drawn but do not specifically identify problems in cardiac function. 2. Urinalysis and blood urea nitrogen (BUN) may be performed but do not specifically identify problems in cardiac function. 3. BNP tests have been shown to positively correlate with pressures in the left ventricle and pulmonary vascular system. As the severity of left ventricular failure increases, BNP levels increase. 4. Serum electrolytes may be drawn but do not specifically identify problems in cardiac function. Page Ref: 1061-1063 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

6 ..

7) The nurse is caring for a patient who has invasive hemodynamic monitoring. What would be the highest priority of care for this patient? 1. Preventing infection at the catheter site by changing the dressing as prescribed 2. Setting alarm limits and turning monitor alarms on 3. Explaining to family members why the monitoring is in use 4. Coiling IV tubing on the bed Answer: 2 Explanation: 1. Preventing infection by changing dressings is important but not the priority of care. 2. Alarms should never be turned off as they are safety devices that warn of a disconnected line or hemodynamic instability. Alarms should always be investigated because they are silenced only when blood is drawn or tubing changed. 3. Keeping family members informed about monitoring is important but is not the priority of care. 4. Coiling the IV tubing on the bed is contraindicated. Page Ref: 1072 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

7 ..

8) The nurse is caring for a patient in the critical care area whose fluid volume status needs to be closely assessed. Which type of monitoring should the nurse expect for this patient? 1. Arterial pressure monitoring 2. Pulmonary artery pressure monitoring 3. Central venous pressure (CVP) monitoring 4. Intra-aortic balloon pump monitoring Answer: 3 Explanation: 1. Arterial pressure monitoring would not measure central venous pressure. 2. Pulmonary artery pressure monitoring is used to evaluate left ventricular and overall cardiac function. 3. CVP is used to monitor fluid volume status. 4. An intra-aortic balloon pump is not used for pressure monitoring. Page Ref: 1064 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.

8 ..

9) A patient has a pulmonary artery (PA) catheter placed. What should the nurse recognize as the purpose of this catheter? 1. The patient cannot tolerate hemodynamic monitoring. 2. The patient requires a peripheral intravenous catheter for medication administration. 3. The patient would benefit from having the right ventricle pressures measured each shift. 4. The patient requires evaluation of left ventricular pressures each shift. Answer: 4 Explanation: 1. PA catheters are a form of hemodynamic monitoring. 2. The PA catheter would not be used to administer medications as it is a central arterial catheter, not a peripheral line. 3. The PA catheter does not measure right ventricular pressures. 4. The PA catheter is used to evaluate left ventricular and overall cardiac function. Page Ref: 1065 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.

9 ..

10) A patient is prescribed digoxin (Lanoxin). What is the nurse's priority instruction to the patient about this medication? 1. How to manage itchy skin 2. Foods that should be eaten while taking this drug 3. The importance of not taking the medication if the pulse is under 60 beats per minute 4. The need to check the pulse once a week and record the result on a notepad Answer: 3 Explanation: 1. Itchy skin is not an adverse effect of this medication. 2. The patient should be instructed to eat foods high in potassium; however, this is not the priority instruction concerning this medication. 3. The highest priority is for the patient to know that it may not be safe to take the drug when the pulse is under 60 beats per minute (bpm) and to contact the physician if that occurs. 4. The pulse should be assessed daily to determine if the medication can be taken. Page Ref: 1067 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

10 ..

11) An older patient with chronic heart failure at home experiences an increase in pulse rate from 80 beats per minute (bpm) to 102 bpm when walking from the kitchen to the utility room to do laundry. What should the nurse encourage the patient to do? 1. Complete tasks such as laundry early in the morning before fatigue is an issue. 2. Ignore the pulse rate and become more active to build stamina. 3. Rest for 30 minutes between loads of laundry. 4. Rest on a chair in the utility room, and sit and rest when the patient feels the pulse rate increase Answer: 4 Explanation: 1. Completing household tasks in the morning is not a practical strategy for an older patient with compromised heart function. 2. Ignoring the pulse rate and becoming more active is not a practical strategy for an older patient with compromised heart function. 3. All home activities should be performed at a pace that is comfortable for the patient. 4. The increase in pulse rate indicates that activity is not being tolerated. Rest should help to bring the heart rate down to the pre-exercise level. Page Ref: 1071 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

11 ..

12) The nurse is caring for a patient with heart failure. Which finding should indicate to the nurse that the patient has decreased cardiac output and tissue perfusion? 1. Reduced mental alertness 2. Increased urine output 3. Abdominal distention 4. Strong peripheral pulses Answer: 1 Explanation: 1. A change in mentation is a common sign of decreased cardiac output and tissue perfusion. 2. Urine output would decrease in this patient. 3. Abdominal distention is a sign of right-sided failure, which is a problem with venous return, not cardiac output or tissue perfusion. 4. Pulses would weaken in this patient. Page Ref: 1071 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

12 ..

13) A patient is exhibiting dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink, frothy sputum. Which health problem should the nurse suspect is occurring in this patient? 1. Chronic heart failure 2. Pulmonary edema 3. Endocarditis 4. Angina Answer: 2 Explanation: 1. Not all patients with chronic heart failure have pink, frothy sputum. 2. Dyspnea, orthopnea, cyanosis, clammy skin, crackles, and a productive cough with pink frothy sputum are signs and symptoms of pulmonary edema, which is considered a medical emergency. 3. Endocarditis would manifest with pain and potentially fever. 4. Angina is chest pain. Page Ref: 1071, 1073 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

13 ..

14) A patient is diagnosed with pulmonary edema. What is a priority for this patient? 1. Inserting a peripheral intravenous catheter 2. Requesting a prescription to medicate the patient for comfort 3. Monitoring the blood glucose level 4. Placing a pulse oximeter and administering oxygen Answer: 4 Explanation: 1. Inserting an IV would be the second priority, although often, if more than one caregiver is present, this action can be done simultaneously. 2. Medication would not be given until the ABCs have been addressed. 3. The blood glucose level is not related to pulmonary edema. 4. Pulmonary edema is a medical emergency. Priority nursing actions focus on maintaining the airway and improving oxygenation, then breathing and circulation. Page Ref: 1076 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

14 ..

15) The nurse is caring for a patient with possible endocarditis. What is important for the nurse to consider when caring for this patient? 1. Endocarditis does not pose a high risk of damage to affected heart valves. 2. Patients with this disorder can be treated with open heart surgery to clean the heart valves. 3. The condition is unrelated to fever, so patients can be medicated with the prescribed antipyretic and observed. 4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures. Answer: 4 Explanation: 1. Endocarditis carries serious risks of damage to heart valves. 2. Open heart surgery is not an appropriate treatment for this condition. 3. Fever may be present in endocarditis. 4. Endocarditis can be prevented in patients at risk by administering antibiotics prior to procedures. Page Ref: 1081 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

15 ..

16) The nurse suspects that a patient has pericarditis. What did the nurse assess to make this clinical decision? Select all that apply. 1. Pericardial friction rub 2. Abdominal discomfort and nausea 3. Chest pain 4. Bradycardia 5. Distended neck veins Answer: 1, 3 Explanation: 1. Pericardial friction is a hallmark sign of pericarditis. 2. Abdominal discomfort and nausea are not associated with pericarditis. 3. Chest pain is a hallmark sign of pericarditis. 4. Bradycardia is not associated with pericarditis. 5. Distended neck veins are not associated with pericarditis. Page Ref: 1077 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

16 ..

17) A patient is diagnosed with cardiac tamponade. What treatment should the nurse expect to be prescribed for this patient? 1. Antidysrhythmic drugs and oxygen 2. Oxygen and rest 3. Pericardiocentesis 4. Antibiotics Answer: 3 Explanation: 1. Antidysrhythmic drugs and oxygen may be indicated after the pericardiocentesis is performed. 2. Oxygen and rest may be indicated after the pericardiocentesis is performed. 3. Cardiac tamponade is a medical emergency. Pericardiocentesis is performed to remove fluid or blood that has collected around the heart and is preventing the heart from pumping effectively. 4. Antibiotics may be indicated after the pericardiocentesis is performed. Page Ref: 1087 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.

17 ..

18) The nurse caring for a patient with coronary artery disease hears a murmur during auscultation of the heart. What should the nurse suspect is occurring in this patient? 1. Valvular heart disease 2. Pericarditis 3. Cardiac tamponade 4. Heart failure Answer: 1 Explanation: 1. Valvular disorders interfere with the smooth flow of blood through the heart. The flow becomes turbulent, causing a murmur, a characteristic manifestation of valvular disease. 2. The heart sound characteristic of pericarditis is a pericardial friction rub. 3. Distant and muffled heart sounds are typical of cardiac tamponade. 4. Extra heart sounds S3 and S4 are heard in heart failure Page Ref: 1090 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

18 ..

19) The nurse suspects that a patient is experiencing paroxysmal nocturnal dyspnea (PND). What did the nurse assess to make this clinical decision? Select all that apply. 1. Symptoms occurring at night 2. Pulmonary congestion 3. Improving cardiac reserve 4. Voiding more than one time per night 5. Daytime peripheral edema Answer: 1, 2, 4, 5 Explanation: 1. PND is a condition in which the patient is awakened at night by acute shortness of breath. 2. PND occurs when edema fluid that has accumulated during the day is reabsorbed into the circulation at night, causing pulmonary congestion. 3. PND is often a symptom of chronic heart failure, which is characterized by decreasing cardiac reserve and dependent edema that worsens as the day progresses. 4. Nocturia, or voiding more than once a night, is associated with PND. 5. Daytime peripheral edema contributes to the development of PND. Page Ref: 1061 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

19 ..

20) Home care teaching is being completed by the nurse for a patient recovering from rheumatic fever. Which patient statement indicates that the teaching has been effective? 1. "I will be sure to tell my dentist that I had rheumatic fever." 2. "I will try to focus on eating less protein and more fat so I will have more energy." 3. "I will avoid brushing my teeth so often and quit using mouth rinse because I have gingivitis." 4. "If my joints start to hurt again, I need to slow down, but I won't have to worry because I'm immune to rheumatic fever now." Answer: 1 Explanation: 1. Antibiotic prophylaxis for invasive procedures such as dental care is important to prevent bacterial endocarditis in the patient recovering from rheumatic fever. 2. Dietary teaching focuses on a high-carbohydrate, high-protein diet to facilitate healing and combat fatigue. 3. Maintaining good oral hygiene and preventive dental care are important to preventing gingival infections, which can lead to recurrence of the disease. 4. Rheumatic fever is manifested by joint pain. One episode of rheumatic fever does not confer immunity to future episodes. Page Ref: 924-1079 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

20 ..

21) The nurse is reviewing data collected on a group of patients. Which patient should the nurse realize is at risk for high-output heart failure? 1. A patient with chronic anemia 2. A person with untreated hypertension 3. An individual with untreated hypothyroidism 4. Someone who abuses sedatives and analgesics Answer: 1 Explanation: 1. High-output heart failure occurs in patients in hypermetabolic states such as anemia. 2. Hypertension is typically associated with low-output heart failure. 3. High-output heart failure occurs in patients in hypermetabolic states such hyperthyroidism. 4. Sedatives and analgesics slow metabolic function. Page Ref: 1061 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

21 ..

22) An older patient with a history of heart failure is experiencing dyspnea, weight gain, chest pain, increasing edema of the lower extremities, and elevated blood pressure. What should the nurse ask to help determine why the patient is currently having health problems? 1. "Are you married?" 2. "Have you been out of the country lately?" 3. "Do you have grandchildren that you babysit?" 4. "Have you attended any recent family or social gatherings?" Answer: 4 Explanation: 1. This question is not relevant to determining the reason for exacerbation of the patient's heart failure. 2. This question is not relevant to determining the reason for exacerbation of the patient's heart failure. 3. This question is not relevant to determining the reason for exacerbation of the patient's heart failure. 4. If the patient has attended a recent family or social gathering in which food was served, it is possible that the sodium content of the food was higher than the patient anticipated. Page Ref: 1072 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

22 ..

23) The nurse is reviewing information received during hand-off communication for a group of patients. Which patient should the nurse assess first? 1. Patient with occasional chest pain who has recently been diagnosed with gallbladder disease 2. Older patient with heart failure who was admitted with increasing edema of the lower extremities 3. Newly admitted patient complaining of substernal chest pain and whose father died recently from heart disease 4. Patient complaining of chest pain and hyperventilating after a family member leaves the room following an argument Answer: 3 Explanation: 1. The patient with gallbladder disease may have chest pain that is not cardiac related. 2. The older patient with increasing edema of the extremities would need evaluation, but after another patient in the group. 3. The nurse would want to assess the newly admitted patient with substernal chest pain and a family history of cardiac disease and initiate any interventions that are appropriate. This manifestation could indicate mitral valve prolapse. 4. The patient who is hyperventilating could be having an anxiety attack but needs to be assessed as soon as possible. Page Ref: 1093 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

23 ..

24) The nurse is caring for patients on a cardiac unit. Which patient should the nurse assess first? 1. Patient with hypertrophic cardiomyopathy who is reporting dyspnea 2. Patient who had a cardiac catheterization and will be ambulating for the first time 3. Patient receiving antibiotics for bacterial endocarditis who is reporting anxiety and chest pain 4. Patient recovering from coronary artery bypass grafting (CABG) surgery with a temperature of 101°F Answer: 3 Explanation: 1. Dyspnea is a chronic symptom with hypertrophic cardiomyopathy, which requires assessment. However, another patient is the most emergent. 2. The patient ambulating for the first time will be assessed by a nurse. However, another patient is the most emergent. 3. The patient with bacterial endocarditis is at risk for thrombus formation. This patient requires immediate attention as chest pain and anxiety are signs of pulmonary embolism (PE), which is life-threatening. 4. A temperature of 101°F requires further assessment. However, another patient is the most emergent. Page Ref: 1081 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

24 ..

25) A patient with endocarditis develops sudden leg pain with pallor, tingling, and loss of peripheral pulses. What should the nurse do first? 1. Notify the physician about these findings. 2. Elevate the leg above the level of the heart. 3. Wrap the extremity in a loose, warm blanket and apply a foot cradle. 4. Perform passive range of motion (PROM) exercises to stimulate circulation. Answer: 3 Explanation: 1. The physician should be notified after the nurse performs another step. 2. Elevating the leg above the heart could worsen the ischemia. 3. The patient is exhibiting symptoms of acute arterial occlusion due to possible embolization of a vegetative lesion. Without immediate intervention, tissue ischemia and necrosis will develop, with ultimate loss of the extremity. The nurse should first wrap the leg in a loose, warm blanket to maintain the temperature and protect the leg from injury, apply a foot cradle, then notify the physician. 4. Passive range of motion exercises will increase tissue demand for oxygen and increase ischemia. Page Ref: 1081 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

25 ..

26) A patient newly diagnosed with heart failure is prescribed 40 mg of furosemide (Lasix) to be given IV push. Knowing that the patient is also prescribed digoxin (Lanoxin), the nurse should review which laboratory result? 1. Sodium level 2. Digoxin level 3. Creatinine level 4. Potassium level Answer: 4 Explanation: 1. Furosemide can cause hyponatremia, but the risk of hypokalemia has more severe consequences in this situation. 2. Heightened digoxin effect can occur in the patient with hypokalemia. 3. There is no data indicating renal insufficiency; therefore, creatinine level is not relevant. 4. The serum potassium level is measured in the patient receiving digoxin and furosemide. Heightened digoxin effect can occur in the patient with hypokalemia. Hypokalemia also predisposes the patient to ventricular dysrhythmias. Page Ref: 1068 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

26 ..

27) A patient is admitted with acute pericarditis. When auscultating heart sounds, which action should the nurse ask the patient to perform? 1. Sit and lean forward while the nurse auscultates at the left lower sternal border. 2. Lie supine and breathe quietly while the nurse auscultates for expiratory wheezes. 3. Sit upright while the nurse auscultates the outer aspects of the upper lobes for vesicular breath sounds. 4. Sit and lean forward while the nurse auscultates at the second right intercostal space, near the sternal border. Answer: 1 Explanation: 1. Pericardial friction rub is the characteristic sign of pericarditis and can be heard best at the left lower sternal border when the patient is sitting and leans forward. The rub is usually heard on expiration and may be constant or intermittent. 2. Expiratory wheezes are not a pericardial friction rub, the characteristic sign of pericarditis. 3. Auscultating lung sounds for vesicular breath sounds is done but does not focus on the pericardial friction rub, the characteristic sign of pericarditis. 4. Auscultating at the second right intercostal space near the sternal border will not help determine the presence of a pericardial friction rub, the characteristic sign of pericarditis. Page Ref: 1086 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with cardiac disorders.

27 ..

28) A patient recovering from replacement of a mitral valve with a mechanical valve asks how long warfarin (Coumadin) needs to be taken. What is the nurse's best response? 1. "You will be on it for the rest of your life because you have a mechanical valve." 2. "That will depend on your surgeon. Ask her when you go to your office visit." 3. "You will be on it for the rest of your life because you have a biologic tissue valve." 4. "You will be told when to stop, usually when your mechanical prosthetic valve is healed and there is a minimal risk of clots." Answer: 1 Explanation: 1. Long-term anticoagulation is necessary with a mechanical prosthetic valve, due to the risk of development of clots on the valve. 2. This does not address the patient's question. 3. Biologic tissue valves have a low risk of thrombus formation and long-term anticoagulation is rarely necessary. 4. Long-term anticoagulation is necessary with a mechanical prosthetic valve. Page Ref: 1097 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.

28 ..

29) A patient is being started on enalapril (Vasotec). Which common adverse effect should the nurse review with the patient? 1. Increased thirst 2. Reduced urine output 3. Persistent cough 4. Loss of appetite Answer: 3 Explanation: 1. Thirst is not a primary adverse effect of an ACE inhibitor. 2. Reduced urine output is not a primary adverse effect of an ACE inhibitor. 3. A primary adverse effect of an ACE inhibitor is a persistent cough. 4. Loss of appetite is not a primary adverse effect of an ACE inhibitor. Page Ref: 1066 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

29 ..

30) The nurse suspects that a patient is experiencing a neuroendocrine response from low cardiac output in heart failure. What manifestation did the nurse assess to make this clinical decision? Select all that apply. 1. Irregular heart rhythm 2. Gastrointestinal bleeding 3. Blood pressure 188/94 mmHg 4. Nausea, vomiting, and diarrhea 5. Heart rate 112 beats per minute Answer: 3, 5 Explanation: 1. Dysrhythmias are not neuroendocrine responses to low cardiac output. 2. Gastrointestinal bleeding is not a neuroendocrine response to low cardiac output. 3. A neuroendocrine response to low cardiac output and decreased renal perfusion is the stimulation of the renin-angiotensin system, which leads to vasoconstriction and increased blood pressure. 4. Nausea, vomiting, and diarrhea are not neuroendocrine responses to low cardiac output. 5. A neuroendocrine response to low cardiac output is stimulation of the sympathetic nervous system and catecholamine release, leading to an increase in heart rate or tachycardia. Page Ref: 1059 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

30 ..

31) During a home visit, the nurse suspects that a patient with heart failure needs additional teaching. What did the nurse observe to make this decision? Select all that apply. 1. The patient lifted an 18-month-old child off the floor. 2. The patient's lunch was a small salad and half a sandwich. 3. The patient drank from a pitcher of water on the coffee table. 4. The patient documented the frequency and amount of walking completed. 5. Working in the kitchen, the patient was obviously sweating and short of breath. Answer: 1, 5 Explanation: 1. Home activity guidelines for the patient with heart failure include no heavy lifting. An 18-month-old child would be considered heavy. 2. Home activity guidelines for the patient with heart failure include eating six small meals a day. 3. Home activity guidelines for the patient with heart failure include drinking plenty of water to avoid constipation. 4. Home activity guidelines for the patient with heart failure include a graded exercise program. 5. Home activity guidelines for the patient with heart failure include stopping any activity that causes sweating or shortness of breath. Page Ref: 1073 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 31.1 Describe the pathophysiology and manifestations of heart failure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

31 ..

32) The nurse is reviewing medications prescribed for a patient with myocarditis. Which medication should the nurse question before administering to the patient? Select all that apply. 1. Antibiotic 2. Anticoagulant 3. Cardiac glycoside 4. Proton pump inhibitor 5. Antidysrhythmic agent Answer: 3, 4 Explanation: 1. Myocarditis is an infection of the heart muscle. Antibiotics are indicated in the treatment of this condition. 2. Emboli can occur with myocarditis. Anticoagulants would be indicated in the treatment of this condition. 3. Patients with myocarditis often are particularly sensitive to the effects of digitalis, which is a cardiac glycoside, so it is used with caution. The nurse should question this medication. 4. Proton pump inhibitors are used for gastrointestinal disorders. The nurse should question this medication. 5. Dysrhythmias can occur with myocarditis. Antidysrhythmic agents are indicated in the treatment of this condition. Page Ref: 1084 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with cardiac disorders.

32 ..

33) The nurse auscultates a heart murmur that is continuous and rumbling and increases in sound toward the end. Which health problem should the nurse suspect this patient might be experiencing? Select all that apply. 1. Mitral stenosis 2. Tricuspid stenosis 3. Mitral regurgitation 4. Aortic regurgitation 5. Tricuspid regurgitation Answer: 1, 2 Explanation: 1. The murmur associated with mitral stenosis is continuous and rumbling and increases in sound toward the end. 2. The murmur associated with tricuspid stenosis is continuous and rumbling and increases in sound toward the end. 3. The murmur associated with mitral regurgitation is continuous and occurs throughout systole. 4. The murmur associated with aortic regurgitation is decrescendo and continuous. 5. The murmur associated with tricuspid regurgitation is continuous and occurs throughout systole. Page Ref: 1091 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

33 ..

34) A patient is having diagnostic tests for aortic regurgitation. Which finding should the nurse expect to assess in this patient? Select all that apply. 1. Dizziness 2. Head bobbing 3. Peripheral edema 4. Throbbing neck pulse 5. Palpitations in the supine position Answer: 1, 2, 4, 5 Explanation: 1. Dizziness is a common manifestation of aortic regurgitation. 2. In aortic regurgitation, the force of contraction may cause a characteristic head bob, or Musset's sign, and shake the whole body. 3. Peripheral edema is not a manifestation of aortic regurgitation. 4. In aortic regurgitation, a throbbing pulse may be visible in the arteries of the neck. 5. In aortic regurgitation, the increased stroke volume may cause complaints of persistent palpitations, especially when the patient is recumbent. Page Ref: 1094 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with cardiac disorders.

34 ..

35) A patient is scheduled for surgery to replace the mitral valve with a biologic heterograft valve. What should the nurse include when instructing the patient about this surgery? Select all that apply. 1. There will be an audible click with this valve. 2. The valve will not need to be replaced. 3. Long-term anticoagulation therapy is not necessary. 4. The valve will likely need to be replaced in 15 years. 5. Long-term antibiotic therapy is needed after the surgery. Answer: 3, 4 Explanation: 1. An audible click is associated with a mechanical valve. 2. Mechanical valves do not necessarily need to be replaced. 3. Long-term anticoagulation therapy is not needed with a biologic valve. 4. Biologic valves are less durable than mechanical valves; up to 50% must be replaced within 15 years. 5. Long-term antibiotic therapy is not needed after valve replacement surgery. Page Ref: 1097 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

35 ..

36) The nurse is completing an assessment of a patient with hypertrophic cardiomyopathy. What intervention should the nurse identify to help this patient with feelings of fatigue? Select all that apply. 1. Organizing care to allow for rest periods 2. Restricting fluids and measuring abdominal girth 3. Reviewing dietary restrictions for sodium intake 4. Assisting with activities of daily living as needed 5. Consulting with physical therapy for an activity plan Answer: 1, 4, 5 Explanation: 1. The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should organize care to allow for rest periods. 2. The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. Restricting fluids and measuring abdominal girth would be appropriate to help manage fluid balance. 3. The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. Reviewing dietary restrictions would be appropriate to help manage fluid balance. 4. The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should assist with activities of daily living as needed. 5. The nursing care of a patient with hypertrophic cardiomyopathy is similar to that of a patient with heart failure. To improve activity intolerance, the nurse should consult with physical therapy for an activity plan. Page Ref: 1104 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 31.3 Describe the pathophysiology and manifestations of disorders of cardiac structure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

36 ..

37) A patient with rheumatic heart disease is being discharged. What should the nurse include in the patient's discharge instructions? Select all that apply. 1. "Perform dental hygiene several times a day." 2. "Complete the full course of prescribed antibiotics." 3. "Take antibiotics as prescribed before dental work." 4. "Restrict fluids and limit activity while taking medication." 5. "Notify the physician if you develop a sore throat or other infection." Answer: 1, 2, 3, 5 Explanation: 1. The patient with rheumatic heart disease should be instructed to perform dental hygiene to avoid gingival infections. 2. The complete course of antibiotics should be taken as prescribed. 3. Antibiotics may be prescribed before dental work. 4. There is no need to restrict fluids and limit activity while taking medication. 5. The physician should be notified if a sore throat or any other signs of infection develop. Page Ref: 1079 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 31.2 Describe the pathophysiology and manifestations of inflammatory heart disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with cardiac disorders.

37 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 32 Nursing Care of Patients with Vascular and Lymphatic Disorders 1) The nurse measures a patient's blood pressure as 144/88 mmHg. What intervention would be most appropriate for this patient? 1. Provide stress-reduction techniques. 2. Inform the physician so antihypertensive medication can be prescribed. 3. Offer the patient a glass of water. 4. Remeasure the blood pressure in a few minutes. Answer: 4 Explanation: 1. The patient may not feel stressed. 2. The patient may not need antihypertensive medication. 3. Offering a glass of water would have no effect on the blood pressure. 4. There is no evidence that this patient has had previously high blood pressure readings. The nurse should remeasure the blood pressure in a few minutes in the event the reading was because of physical activity or anxiety. Hypertension is defined as systolic blood pressure of 130 mmHg or higher, or diastolic pressure of 90 mmHg or higher, based on the average of three or more readings taken on separate occasions. Page Ref: 1110 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

1 ..

2) A patient with diabetes is beginning treatment for hypertension. What should the nurse explain as being the blood pressure treatment goal for this patient? 1. 140/90 mmHg 2. 135/85 mmHg 3. 130/80 mmHg 4. 120/80 mmHg Answer: 4 Explanation: 1. Hypertension management focuses on reducing the blood pressure to less than 140 mmHg systolic and 90 mmHg diastolic. 2. This is incorrect. 3. The risk of cardiovascular complications decreases when the average blood pressure is less than 140/90; however, when the patient also has diabetes or renal disease, the treatment goal is a blood pressure less than 120/80 mmHg. 4. When the patient also has diabetes or renal disease, the treatment goal is a blood pressure less than 120/80 mmHg. Page Ref: 1112 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

2 ..

3) The nurse is instructing a patient with hypertension about lifestyle modifications. What would be appropriate to include in the teaching for this patient? Select all that apply. 1. Review the DASH diet. 2. Begin a walking program, and progress to 30 minutes 5 to 6 days each week. 3. Plan a weight lifting regimen. 4. Eliminate dairy products from the diet. 5. Restrict fluid intake. Answer: 1, 2 Explanation: 1. Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium and calcium intakes, and reducing total and saturated fat intake. The DASH diet has proven beneficial effects in lowering blood pressure. 2. Regular exercise reduces blood pressure and contributes to weight loss, stress reduction, and feelings of overall well-being. Previously sedentary patients are encouraged to engage in aerobic exercise for 30 to 45 minutes per day most days of the week. 3. Isometric exercise, such as weight training, may not be appropriate, as it can raise the systolic blood pressure. 4. Dietary approaches to managing hypertension focus on reducing sodium intake, maintaining adequate potassium and calcium intakes, and reducing total and saturated fat intake. 5. Fluid restriction is not indicated. Page Ref: 1113 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

3 ..

4) A patient's blood pressure continues to be elevated despite being prescribed an ACE inhibitor for several weeks. What should the nurse do at this time? 1. Ask if the patient is taking the prescribed medication. 2. Suggest to the physician that another medication be added. 3. Schedule the patient to have the blood pressure checked again in a week. 4. Realize the patient is anxious because of the diagnosis. Answer: 1 Explanation: 1. Noncompliance, or failure to follow the identified treatment plan, is a continuing risk for any patient with a chronic disease. Prescribed medications may have undesirable effects, whereas hypertension itself often has no symptoms or noticeable effects. The nurse should inquire about reasons for noncompliance with the recommended treatment plan by assessing for factors that can contribute to noncompliance, such as adverse drug effects. If it is determined that the patient is not taking the prescribed medication, the other interventions would not be indicated at this time. 2. Further assessment is indicated prior to this intervention. 3. Further assessment is indicated prior to this intervention. 4. There is no evidence of the patient being anxious because of the diagnosis. Page Ref: 1119 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.

4 ..

5) During the abdominal assessment of an elderly patient, the nurse palpates a mass in the midabdomen. What should the nurse do next? 1. Percuss the mass. 2. Ask the patient to cough. 3. Get the physician. 4. Auscultate the mass. Answer: 4 Explanation: 1. If an aneurysm were suspected, percussing the mass would be inappropriate because it could increase the pressure on the weakened site. 2. If an aneurysm were suspected, asking the patient to cough is inappropriate because it could increase the pressure on the weakened site. 3. Further assessment is needed before contacting the physician. 4. Most abdominal aneurysms are asymptomatic, but a pulsating mass in the mid- and upper abdomen and a bruit (the sound auscultated over turbulent or restricted blood flow) over the mass are found on examination. Page Ref: 1126 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

5 ..

6) The nurse suspects a patient recovering from an abdominal aortic aneurysm repair is experiencing graft leaking. What finding did the nurse use to make this clinical decision? Select all that apply. 1. Urine output 45 mL/hr 2. Complaint of groin pain 3. Abdominal dressing dry and intact 4. Respiratory rate 16 and regular 5. Complaint of back discomfort Answer: 2, 5 Explanation: 1. The nurse would not report the output unless it was less than 30mL/hour. 2. The nurse should monitor for and report groin pain. 3. A dry and intact abdominal dressing is a normal finding. 4. A respiratory rate of 16 and regular is a normal finding. 5. The nurse should monitor for and report any back pain. Page Ref: 1127 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.

6 ..

7) The nurse suspects that a patient is experiencing the effects of peripheral atherosclerosis. What did the nurse most likely assess in this patient? 1. Rubor with extremity elevation 2. Normal hair distribution bilaterally over lower extremities 3. Peripheral pulses present bilaterally 4. Complaints of leg pain upon rest Answer: 4 Explanation: 1. Manifestations of peripheral atherosclerosis include pallor with extremity elevation and rubor with extremities in dependent position. 2. Manifestations of peripheral atherosclerosis include thin, shiny, hairless skin. 3. Manifestations of peripheral atherosclerosis include diminished or absent peripheral pulses. 4. Manifestations of peripheral atherosclerosis include intermittent claudication; pain at rest; paresthesias; diminished or absent peripheral pulses; pallor with extremity elevation; rubor with extremities in dependent position; thin, shiny, hairless skin; thickened toenails; and areas of skin discoloration or skin breakdown. Page Ref: 1131 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

7 ..

8) A patient is having segmental pressure measurements conducted to help diagnose peripheral vascular disease. What finding would indicate the presence of this disorder? 1. Thigh pressure higher than the arm 2. Calf pressure higher than the arm 3. Calf pressure lower than the arm 4. No difference between the arm and leg Answer: 3 Explanation: 1. In peripheral vascular disease (PVD), the thigh pressure is not higher than the arm. 2. In peripheral vascular disease (PVD), the calf pressure is not higher than the arm. 3. Noninvasive studies often are sufficient to diagnose peripheral vascular disease. Segmental pressure measurements use sphygmomanometer cuffs and a Doppler device to compare blood pressures between the upper and lower extremities and within different segments of the affected extremity. In peripheral vascular disease (PVD), the blood pressure may be lower in the legs than in the arms. 4. In peripheral vascular disease (PVD), there is a difference between arm and leg blood pressure. Page Ref: 1131 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

8 ..

9) A patient is demonstrating signs of ineffective peripheral tissue perfusion. What intervention would be appropriate for this patient? 1. Encourage patient to reduce level of exercise. 2. Discuss smoking cessation techniques. 3. Keep extremities cool. 4. Assist with pillow placement under knees. Answer: 2 Explanation: 1. Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include discussing the benefits of regular exercise. 2. Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include instructing the patient to avoid smoking. Nicotine is a potent vasoconstrictor that further impairs arterial blood flow. 3. Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include keeping extremities warm and avoiding electric heating pads or hot water bottles. 4. Interventions for a patient who is experiencing ineffective peripheral tissue perfusion include instructing to avoid crossing legs or using a pillow under the knees. Page Ref: 1133 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

9 ..

10) A patient is diagnosed with thromboangiitis obliterans. What would be appropriate teaching for this patient? 1. Medications are the only cure. 2. Surgical procedures can be performed to cure this disorder. 3. Management depends upon the patient's willingness to stop smoking. 4. Nothing can help manage this disorder. Answer: 3 Explanation: 1. Medications do not cure this disorder. 2. Surgical procedures to not cure this disorder. 3. The prognosis for thromboangiitis obliterans depends significantly on the patient's ability and willingness to stop smoking. With smoking cessation and good foot care, the prognosis for saving the extremities is good, even though no cure is available. 4. With smoking cessation and good foot care, the prognosis for saving the extremities is good, even though no cure is available. Page Ref: 1136 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

10 ..

11) A patient is being discharged on long-term oral anticoagulant therapy for arterial thrombus formation in the lower extremity. What should be included in this patient's discharge instructions? 1. Slight bleeding from the nose is expected. 2. Contact the physician's office for follow-up laboratory studies. 3. Pain in the limb is a sign of healing. 4. Take two doses of the prescribed anticoagulant if a dose is missed one day. Answer: 2 Explanation: 1. Nasal bleeding is not expected. 2. When preparing the patient and family for home or community-based care related to an acute arterial occlusion, the patient should be instructed to follow-up with laboratory testing and appointments. 3. Pain in the limb could indicate another clot has formed. 4. Anticoagulant medications should never be "doubled" even in the case of a missed dose. The patient would be encouraged to notify the physician if a dose is missed. Page Ref: 1140 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

11 ..

12) A patient is demonstrating signs of thrombophlebitis. Which mechanism should the nurse expect has occurred with this health problem? Select all that apply. 1. Pooling of blood in the vessel 2. Blood hypercoagulation 3. Stasis of blood flow 4. Elevated systemic blood pressure 5. Vessel damage Answer: 2, 3, 5 Explanation: 1. Blood does not pool in the vessel; it is restricted. 2. Three pathologic factors, called Virchow's triad, are associated with thrombophlebitis. One pathologic factor is blood coagulability. 3. Three pathologic factors, called Virchow's triad, are associated with thrombophlebitis. One pathologic factor is stasis of blood. 4. Systemic blood pressure elevation is not a mechanism of this problem. 5. Three pathologic factors, called Virchow's triad, are associated with thrombophlebitis. One pathologic factor is vessel damage. Page Ref: 1141 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

12 ..

13) A patient is seen for increasing edema in his left lower extremity and pain in the limb with ambulation. What should the nurse suspect is occurring in this patient? 1. Arterial occlusion 2. Deep vein thrombosis 3. Superficial vein thrombosis 4. Varicose veins Answer: 2 Explanation: 1. These manifestations are not associated with an arterial occlusion. 2. The manifestations of deep vein thrombosis (DVT) are primarily due to the inflammatory process that accompanies the thrombus. Calf pain is the most common symptom, and it may be described as tightness or a dull, aching pain in the affected extremity, particularly upon walking. 3. These are not manifestations of a superficial venous thrombosis. 4. Varicose veins are tortuous veins with valve insufficiency. Page Ref: 1141 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

13 ..

14) A patient with a deep vein thrombosis (DVT) is going to be weaned from intravenous heparin. When should the nurse anticipate that oral warfarin sodium would be prescribed? 1. The same day the heparin is discontinued 2. The day before the heparin is discontinued 3. Four to five days before the heparin is discontinued 4. The same day as the heparin is started Answer: 3 Explanation: 1. Oral warfarin sodium will not be prescribed the same day the heparin is discontinued. 2. Oral warfarin sodium will not be prescribed the day before the heparin is discontinued. 3. Oral anticoagulation with warfarin may be initiated concurrently with heparin therapy. Overlapping heparin and warfarin therapy for four to five days is important because the full anticoagulant effect of warfarin is delayed, and it may actually promote clotting during the first few days of therapy. 4. Oral warfarin sodium will not be prescribed the same day the heparin is started. Page Ref: 1143 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

14 ..

15) The nurse is planning care for a patient who was diagnosed with deep vein thrombosis (DVT). What should be included in this plan of care? 1. Activity as tolerated. 2. Measure and apply elastic antiembolism stockings. 3. Encourage the patient to sit out of bed several hours every day. 4. Assist patient with putting on tight-fitting pants. Answer: 2 Explanation: 1. The plan of care for a patient with deep vein thrombosis (DVT) includes possible bed rest, the duration of which is determined by the extent of leg edema. 2. Elastic antiembolism stockings are frequently ordered to stimulate the muscle-pumping mechanism that promotes the return of blood to the heart. 3. The patient should be instructed to avoid prolonged standing, sitting, and to avoid leg crossing. 4. The patient should be instructed to avoid tight-fitting garments. Page Ref: 1146 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

15 ..

16) A patient who is being treated for a deep vein thrombosis (DVT) complains of chest pain and shortness of breath. What should the nurse do first? 1. Elevate the head of the bed and begin oxygen therapy. 2. Measure the patient's blood pressure. 3. Assess the extremity with the thrombosis. 4. Assess the pulses on the extremity with the thrombosis. Answer: 1 Explanation: 1. Immediately report patient complaints of chest pain and shortness of breath, anxiety, or a sense of impending doom. Prompt intervention to restore pulmonary blood flow can reduce the risk of significant adverse effects. Initiate oxygen therapy and elevate the head of the bed. 2. Measuring the patient's blood pressure is not the priority and would delay the initiation of required interventions in this situation. 3. Assessing the extremity with the thrombosis is not the priority and would delay the initiation of required interventions in this situation. 4. Assessing the pulses on the extremity with the thrombosis is not the priority and would delay the initiation of required interventions in this situation. Page Ref: 1147 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.

16 ..

17) An older patient is diagnosed with chronic venous insufficiency. What should the nurse instruct this patient? 1. Keep legs in a dependent position as much as possible. 2. Avoid the use of knee-high hose or girdles. 3. Limit ambulation. 4. Dangle legs over the side of the bed several times per day. Answer: 2 Explanation: 1. Patients should be instructed to elevate the legs while resting and during sleep. 2. Patients should be instructed not to wear anything that pinches legs, such as knee-high hose, garters, or girdles and to wear elastic hose as prescribed. 3. Patients should be instructed to walk as much as possible. 4. Patients should be instructed to avoid sitting or standing for long periods of time; when sitting, do not cross legs or allow pressure on the back of the knees, such as sitting on the side of the bed. Page Ref: 1150 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

17 ..

18) An older patient is prescribed elastic graduated compression stockings. What should the nurse instruct the patient about these stockings? 1. Wear the stockings continuously, except when showering. 2. Expect areas of skin breakdown under the stockings. 3. Wear the stockings primarily while sleeping. 4. Remove the stockings once per day and while sleeping. Answer: 4 Explanation: 1. The stocking should be removed once per day. 2. Skin breakdown is not anticipated with wearing the stockings and would need to be reported to the physician. 3. The stockings do not need to be removed for sleep. 4. Elastic compression stockings compress the veins, promoting venous return from the lower extremities. Because elastic stockings inhibit blood flow through small superficial vessels, they should be removed at least once each day for at least 30 minutes. Page Ref: 1152 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

18 ..

19) The nurse is teaching a community education class on hypertension and risk factors for this disorder. What is the primary risk factor leading to the higher incidence of hypertension in older adults? 1. Being a black adult 2. Being a white male 3. Having a family history of hypertension 4. Age-related increase in the systolic blood pressure Answer: 4 Explanation: 1. Being a black adult is a risk factor for hypertension but not the primary risk factor. 2. Being a white male is a risk factor for hypertension but not the primary risk factor. 3. Having a family history is a risk factor for hypertension but not the primary risk factor. 4. An age-related increase in the systolic blood pressure is the primary factor leading to the high incidence of hypertension in older adults. Systolic blood pressure continues to rise with aging, unlike the diastolic blood pressure, which tends to rise until age 50 and then levels off. Page Ref: 1111 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

19 ..

20) A patient is diagnosed with a disorder in which deoxygenated blood is having difficulty returning to the heart and lungs for reoxygenation. In which part of the peripheral vascular system is the origin of this patient's disorder? 1. Arteries 2. Arterioles 3. Capillaries 4. Venules Answer: 4 Explanation: 1. Arteries and arterioles are vessels within the arterial network, not the venous network. 2. Arteries and arterioles are vessels within the arterial network, not the venous network. 3. In the capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and deoxygenated blood begins its journey back to the heart. The problem with blood returning to the heart is not based in the capillaries. 4. In the capillary beds, oxygen and nutrients are exchanged for metabolic wastes, and deoxygenated blood begins its journey back to the heart through venules, the smallest vessels of the venous network. The venous network is where the problem with blood returning to the heart resides. Page Ref: 1140 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

20 ..

21) A patient with some blood loss is maintaining a blood pressure of 100/60 mmHg. Which structure is most likely maintaining the patient's blood pressure? 1. Arterioles 2. Venules 3. Capillaries 4. Veins Answer: 1 Explanation: 1. The smaller arterioles are less elastic than arteries but contain more smooth muscle, which promotes their constriction (narrowing) and dilation (widening). In fact, arterioles exert the major control over arterial blood pressure. With blood loss, the arterioles would constrict as a compensation mechanism to increase blood pressure. 2. This would not happen at the capillary level and is possible in the arterial system, not the venous system. 3. This would not happen at the capillary level and is possible in the arterial system, not the venous system. 4. This would not happen at the capillary level and is possible in the arterial system, not the venous system. Page Ref: 1109 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

21 ..

22) A patient is demonstrating a sign of blood pressure stabilization accompanied by a decreased urine output. What should the nurse explain is the body's mechanism responsible for this blood pressure stabilization? 1. Response to chemoreceptors in the aortic arch 2. Renal conservation of sodium and water 3. Change in body temperature 4. Intake of dietary fat and protein Answer: 2 Explanation: 1. The changes are not reflective of intervention influenced by the chemoreceptors in the aortic arch, body temperature changes, or dietary intake. 2. Blood pressure is influenced by many factors. The kidneys help maintain blood pressure by excreting or conserving sodium and water. When blood pressure decreases, the kidneys initiate the renin-angiotensin mechanism. This stimulates vasoconstriction, which results in the release of the hormone aldosterone from the adrenal cortex, and increases sodium ion reabsorption and water retention. In addition, pituitary release of antidiuretic hormone (ADH) promotes renal reabsorption of water. The net result is an increase in blood volume and a consequent increase in cardiac output and blood pressure. With the changes described, the kidneys are compensating and causing the changes. 3. The changes are not reflective of intervention influenced by the chemoreceptors in the aortic arch, body temperature changes, or dietary intake. 4. The changes are not reflective of intervention influenced by the chemoreceptors in the aortic arch, body temperature changes, or dietary intake. Page Ref: 1109 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

22 ..

23) The nurse suspects that a patient's hypertension is being influenced by sympathetic nervous system stimulation. Which substance should the nurse identify as contributing to this patient's elevated blood pressure? Select all that apply. 1. Epinephrine 2. Angiotensin II 3. Norepinephrine 4. Adrenomedullin 5. Antidiuretic hormone Answer: 1, 2, 3, 5 Explanation: 1. Epinephrine is a vasoconstrictor and will increase blood pressure. 2. Angiotensin II is a hormone that increases blood pressure. 3. Norepinephrine is a vasoconstrictor that increases blood pressure. 4. Adrenomedullin is a hormone that decreases blood pressure. 5. Antidiuretic hormone is a vasoconstrictor that increases blood pressure. Page Ref: 1109 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

23 ..

24) A patient makes an appointment to see the primary healthcare provider because during a routine eye examination the ophthalmologist asked how long the patient had been treated for hypertension. What did the ophthalmologist observe that caused the health problem of hypertension to be discussed? Select all that apply. 1. Nystagmus 2. Papilledema 3. Astigmatism 4. Retinal exudates 5. Retinal hemorrhages Answer: 2, 4, 5 Explanation: 1. Nystagmus is not caused by changes in the eye resulting from hypertension. 2. Manifestations of hypertension result from target organ damage, including the eyes. Eye changes include papilledema or swelling of the optic nerve. 3. Astigmatism is not caused by changes in the eye resulting from hypertension. 4. Manifestations of hypertension result from target organ damage, including the eyes. Eye changes include retinal exudates. 5. Manifestations of hypertension result from target organ damage, including the eyes. Eye changes include retinal hemorrhages. Page Ref: 1112 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

24 ..

25) A patient with hypertension is prescribed the alpha-adrenergic blocker doxazosin (Cardura). What should the nurse instruct the patient about this medication? Select all that apply. 1. Take the medication at bedtime. 2. Change positions slowly and sit down if dizziness occurs. 3. Notify the primary healthcare provider if nasal congestion develops. 4. Restrict the intake of all alcoholic beverages and items containing caffeine. 5. Avoid engaging in hazardous activity for 12 to 24 hours after the first dose. Answer: 1, 2, 3, 5 Explanation: 1. Because of the risk of fainting after taking the first dose of this medication, the medication should be taken at bedtime. 2. This drug can cause dizziness. The patient should change positions slowly and sit down if dizziness occurs. 3. The primary healthcare provider should be notified if nasal congestion occurs. 4. There is no need to restrict the intake of alcoholic beverages and items containing caffeine while taking this medication. 5. Because of the risk of fainting, the patient should not drive or engage in hazardous activity for 12 to 24 hours after taking the first dose. Page Ref: 1115 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

25 ..

26) A patient with hypertension weighing 115 kg is advised by the primary healthcare provider to lose 10% of total body weight over the next 6 months. How many lbs. of weight loss per month should the nurse instruct the patient to establish as a goal? Record your answer rounding to the nearest whole number. Answer: 4 lbs. Explanation: The patient weighs 115 kg. To convert this weight into lbs. multiply the weight in kg by 2.2 lbs. or 115 × 2.2 = 253 lbs. The patient is counseled to lose 10% of total body weight or 253 lbs. × 10% = 25.3 lbs. If this weight is to be lost over 6 months, divide the total weight to lose by 6 or 25.3/6 = 4.216 lbs. When rounding to the nearest whole number, the patient should set a goal to lose 4 lbs. per month. Page Ref: 1119 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

26 ..

27) A patient is suspected as having secondary hypertension. For which diagnostic test should the nurse prepare this patient? Select all that apply. 1. Bladder scan 2. Renal lithotripsy 3. Renal ultrasound 4. Renal arteriogram 5. Intravenous pyelogram Answer: 3, 4, 5 Explanation: 1. A bladder scan determines the amount of residual urine in the bladder. 2. Renal lithotripsy is done when renal calculi are diagnosed. 3. In secondary hypertension, a renal cause needs to be ruled out. A renal ultrasound might be prescribed for this patient. 4. In secondary hypertension, a renal cause needs to be ruled out. A renal arteriogram might be prescribed for this patient. 5. In secondary hypertension, a renal cause needs to be ruled out. An intravenous pyelogram might be prescribed for this patient. Page Ref: 1123 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

27 ..

28) While conducting an assessment, the nurse suspects that a patient is experiencing a hypertensive crisis. What did the nurse assess to make this clinical decision? Select all that apply. 1. Acute onset of confusion 2. Onset of projectile vomiting 3. Complaints of a severe headache 4. Systolic blood pressure 198 mmHg 5. Diastolic blood pressure 148 mmHg Answer: 1, 3, 4, 5 Explanation: 1. Manifestations of hypertensive crisis include confusion. 2. Projectile vomiting is not a manifestation of hypertensive crisis. 3. Manifestations of hypertensive crisis include headache. 4. Manifestations of hypertensive crisis include systolic blood pressure greater than 180 mmHg. 5. Manifestations of hypertensive crisis include diastolic blood pressure greater than 120 mmHg. Page Ref: 1123 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.1 Describe the pathophysiology and manifestations of disorders of blood pressure, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.

28 ..

29) A patient is experiencing a new onset of hoarseness. What additional assessment finding should the nurse use to suspect that this patient is experiencing a thoracic aneurysm? Select all that apply. 1. Brassy cough 2. Lumbar back pain 3. Edema of the face 4. Distended neck veins 5. Absent pulses in the wrists Answer: 1, 3, 4 Explanation: 1. Manifestations of a thoracic aneurysm include a brassy cough if pressing on the trachea. 2. Lumbar pain is associated with an abdominal aneurysm. 3. Manifestations of a thoracic aneurysm include edema of the face. 4. Manifestations of a thoracic aneurysm include distended neck veins. 5. Absent pulses in the wrists are associated with an aortic aneurysm. Page Ref: 1125 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

29 ..

30) A patient is diagnosed with an aortic dissection. Which medication should the nurse expect to be prescribed for this patient? Select all that apply. 1. Verapamil (Isoptin) 2. Esmolol (Brevibloc) 3. Diltiazem (Cardizem) 4. Hydralazine (Apresoline) 5. Sodium nitroprusside (Nipride) Answer: 1, 2, 3, 5 Explanation: 1. Calcium channel blockers such as verapamil (Isoptin) may be used to treat aortic dissection. 2. Patients with aortic dissection are initially treated with intravenous beta-blockers such as esmolol (Brevibloc) to reduce the heart rate to about 60 bpm. 3. Calcium channel blockers such as diltiazem (Cardizem) may be used to treat aortic dissection. 4. Direct vasodilators such as hydralazine (Apresoline) are avoided because they may actually worsen the dissection. 5. Sodium nitroprusside (Nipride) infusion may be started to reduce the systolic pressure to 120 mmHg or less. Page Ref: 1127 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

30 ..

31) The nurse is concerned that a patient recovering from surgery to repair an abdominal aneurysm is developing bowel ischemia. What assessment finding did the nurse use to come to this conclusion? Select all that apply. 1. Diarrhea 2. Obvious bloody stool 3. Abdominal distention 4. Onset of abdominal pain 5. Hyperactive bowel sounds Answer: 1, 2, 3, 4 Explanation: 1. Manifestations of bowel ischemia include diarrhea. 2. Manifestations of bowel ischemia include occult or fresh blood in stools. 3. Manifestations of bowel ischemia include abdominal distention. 4. Manifestations of bowel ischemia include abdominal pain. 5. A change in bowel sounds is not a manifestation of bowel ischemia. Page Ref: 1129 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.2 Describe the pathophysiology and manifestations of disorders of the aorta and its branches, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.

31 ..

32) The nurse instructs a patient with peripheral atherosclerosis on foot care. Which observation indicates that teaching has been effective? Select all that apply. 1. The patient uses a razor to cut the toenails. 2. The patient walks barefoot in the bedroom. 3. The patient washes feet and legs with warm water. 4. The patient applies powder to the feet after a shower. 5. The patient inspects feet and legs each day with a mirror. Answer: 3, 4, 5 Explanation: 1. A professional foot care provider should trim toenails. 2. The patient should be instructed always to wear shoes and not to go barefoot. 3. Foot care for the patient with peripheral atherosclerosis includes washing the feet and legs with warm water. 4. Foot care for the patient with peripheral atherosclerosis includes applying powder to the feet after a shower. 5. Foot care for the patient with peripheral atherosclerosis includes inspecting the feet and legs each day with a mirror. Page Ref: 1132 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

32 ..

33) The nurse contacts the healthcare provider after assessing a patient's left lower leg. What did the nurse assess to make this decision? Select all that apply. 1. Absent pedal pulses 2. Skin cold to the touch 3. +4 edema on the ankle 4. Foot unresponsive to sensation 5. Line of demarcation across the foot Answer: 1, 2, 4, 5 Explanation: 1. Manifestations of arterial thrombosis include absent distal pulses. 2. Manifestations of arterial thrombosis include tissue that is cool or cold. 3. Edema is not a manifestation of arterial thrombosis. 4. Manifestations of arterial thrombosis include paralysis of the affected extremity. 5. Manifestations of arterial thrombosis include a line of demarcation between normal and ischemic tissue. Page Ref: 1138 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.3 Describe the pathophysiology and manifestations of disorders of the peripheral arteries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with vascular and lymphatic disorders.

33 ..

34) A patient with a history of recurrent venous micro emboli is scheduled for an insertion of a Greenfield filter. What should the nurse explain to the patient about this procedure? Select all that apply. 1. The filter can be inserted under fluoroscopy. 2. Mortality from the insertion of the filter is low. 3. The filter will need to be replaced every 6 months. 4. The patient may only need local anesthesia for the procedure. 5. The filter traps emboli while maintaining the patency of the vena cava. Answer: 1, 2, 4, 5 Explanation: 1. The filter can be inserted under fluoroscopy. 2. Mortality associated with the filter is very low. 3. There is no information to support the frequency in which the filter needs to be replaced. 4. The filter can be inserted with local anesthesia. 5. The Greenfield filter is widely used for its ability to trap emboli within its apex while maintaining patency of the vena cava. Page Ref: 1145 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

34 ..

35) A patient with a history of deep venous thrombosis is prescribed rivaroxaban (Xarelto). What should the nurse instruct the patient about this medication? Select all that apply. 1. Use a straight razor to shave if necessary. 2. Limited amounts of alcohol are permitted. 3. A reversal agent for this medication is not available. 4. The cost of this medication is higher than for warfarin. 5. Laboratory test monitoring is not necessary for this medication. Answer: 3, 4, 5 Explanation: 1. The patient should be instructed to prevent injury and bleeding. A straight razor would be contraindicated. 2. Alcohol should be avoided while taking this medication. 3. Rivaroxaban (Xarelto) acts as a selective factor X inhibitor, inactivating the cascade of coagulation. There is no reversal agent available for this drug. 4. Rivaroxaban (Xarelto) acts as a selective factor X inhibitor, inactivating the cascade of coagulation. The cost is significantly higher for this drug when compared to warfarin. 5. Rivaroxaban (Xarelto) acts as a selective factor X inhibitor, inactivating the cascade of coagulation. This drug does not require monitoring like warfarin does. Page Ref: 1144 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

35 ..

36) The nurse completes an assessment with a patient and begins planning care for a venous leg ulcer. What manifestation did the nurse use to make this clinical decision? Select all that apply. 1. There is an ulcer located on the toe. 2. The ulcer is superficial and pink. 3. Pulses in the foot are decreased. 4. Skin over the leg is discolored brown. 5. The patient rates pain as 8 on a scale from 0 to 10. Answer: 2, 4 Explanation: 1. An ulcer on the toe is associated with an arterial ulcer. 2. Manifestations of a venous ulcer include a superficial wound that is pink. 3. Decreased pulses in the foot are associated with an arterial ulcer. 4. Manifestations of a venous ulcer include brown skin discoloration over the lower extremity. 5. Severe pain is associated with an arterial ulcer. Page Ref: 1149 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with vascular and lymphatic disorders.

36 ..

37) A patient is recovering from surgery for varicose veins. What information should the nurse include in this patient's postoperative teaching? Select all that apply. 1. Elevate the extremities. 2. Increase ambulation gradually. 3. Sit for no more than 1 hour at a time. 4. Avoid standing for more than 15 minutes. 5. Keep pressure dressing applied for 6 weeks. Answer: 1, 2, 5 Explanation: 1. Postoperative care for varicose veins includes elevating the extremities to minimize postoperative edema. 2. Postoperative care for varicose veins includes gradually increasing amounts of ambulation. 3. Sitting is prohibited during the initial recovery period, and is gradually reintroduced as deemed appropriate by the surgeon. 4. Standing is prohibited during the initial recovery period, and is gradually reintroduced as deemed appropriate by the surgeon. 5. Postoperative care for varicose veins includes applying pressure bandages for a minimum of 6 weeks. Page Ref: 1152 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.4 Describe the pathophysiology and manifestations of disorders of venous circulation, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

37 ..

38) A patient is diagnosed with lymphedema. Which treatment should the nurse expect to be prescribed for this patient? Select all that apply. 1. Consider microvascular surgery. 2. Apply powder to the feet after daily cleansing. 3. Measure for elastic graduate compression stockings. 4. Intermittent pneumatic compression device for home use. 5. Limit wearing of shoes when in the home or a controlled environment. Answer: 1, 3, 4 Explanation: 1. Patients who do not respond to conservative treatment measures or who experience recurrent episodes of cellulitis and lymphangitis may require surgical treatment. Microvascular techniques may be used to create anastomoses between obstructed lymphatic vessels and adjacent veins, providing channels to redirect lymph into the venous system. 2. Careful cleansing and use of emollient lotions are recommended to prevent drying of the skin. 3. Elastic graduate compression stockings may be prescribed for use during the day. 4. In some cases, an intermittent pneumatic compression device to reduce edema may be prescribed for home use. 5. Shoes should always be worn to reduce the risk of injury. Page Ref: 1154-1155 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 32.5 Describe the pathophysiology and manifestations of disorders of the lymphatic system, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with vascular and lymphatic disorders.

38 ..

39) A patient with lymphedema asks why the legs need to be elevated throughout the day. Which information should the nurse include when responding to this patient? Select all that apply. 1. Prevents tissue hypoxia 2. Promotes venous return 3. Facilitates arterial circulation 4. Decreases venous congestion 5. Reduces fluid in interstitial spaces Answer: 2, 3, 4, 5 Explanation: 1. Elevation of the legs is not done to prevent tissue hypoxia. 2. For lymphedema, the extremities should be elevated while seated and during sleep to promote venous return. 3. For lymphedema, the extremities should be elevated while seated and during sleep to facilitate arterial circulation. 4. For lymphedema, the extremities should be elevated while seated and during sleep to decrease venous congestion. 5. For lymphedema, the extremities should be elevated while seated and during sleep to reduce fluid in interstitial spaces. Page Ref: 1155 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 32.5 Describe the pathophysiology and manifestations of disorders of the lymphatic system, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with vascular and lymphatic disorders.

39 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 33 Nursing Care of Patients with Hematologic Disorders 1) The nurse is caring for a young female patient whose laboratory values indicate the presence of microcytic and hypochromic red blood cells. What should the nurse do to help this patient? 1. Enforce "nothing by mouth" in anticipation of emergency surgery. 2. Insert an intravenous access line for fluids. 3. Consult with the dietitian for a diet high in iron. 4. Assess the past history for risks of bleeding or menstrual changes. Answer: 4 Explanation: 1. Emergency surgery is not the first action, as microcytic and hypochromic RBCs reflect a chronic bleeding condition, not an acute one. 2. Fluid replacement would not address the blood cells' reduced ability to carry oxygen. 3. Although a dietitian might be needed to instruct the patient on a diet high in iron, this would not be the nurse's first action. 4. The nurse should do additional health history assessment to identify the source of chronic bleeding. Questions related to length and amount of menstrual flow, color of stools, and any upper gastric bleeding/conditions that might be contributing to the potential bleeding should be asked before any other actions are taken. Page Ref: 1162 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

1 ..

2) A middle-aged female with numbness and tingling in the lower extremities and difficulty ambulating has large, oval-shaped, macrocytic red blood cells with thin membranes on the latest complete blood count. Which therapy would the nurse anticipate including in the discharge plan? 1. A diet high in green leafy vegetables, broccoli, wheat germ, and asparagus 2. A daily multivitamin with extra iron 3. Instructions about subcutaneous injections of erythropoietin for a few weeks 4. Instructions about intramuscular parenteral injections of vitamin B12 for the rest of her life Answer: 4 Explanation: 1. Green leafy vegetables, broccoli, wheat germ, and asparagus are high in folic acid but not another important nutrient. 2. Iron deficiency results in microcytic and hypochromic RBCs. Extra iron and vitamins will not correct the symptoms. 3. Erythropoietin stimulates new RBC production by the bone marrow, but if another substance is deficient, the RBCs will not have the shape or size of normal RBCs. 4. Because vitamin B12 is important for neurologic function, deficiency leads to paresthesias in the extremities and problems with proprioception. Treatment for vitamin B12 deficiency is oral or parenteral vitamin B12 supplements. Page Ref: 1164, 1170 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

2 ..

3) A patient is admitted with the diagnosis of sickle-cell crisis. What action should the nurse take first if the patient has a temperature of 102°F, O2 saturation 89%, and severe abdominal pain? 1. Give Tylenol (acetaminophen) grains X (650 mg). 2. Administer oxygen as prescribed. 3. Administer morphine sulfate IM. 4. Assess and document peripheral pulses. Answer: 2 Explanation: 1. Although the temperature is elevated and will increase oxygen demands in the body by increased basal metabolic activity, this is not the first action the nurse should take, because sickling crisis is caused by oxygen deprivation in tissues, not by the fever. 2. Hypoxia is often the cause of sickling crisis from the clumping of damaged RBCs, which creates an obstruction and hypoxia distal to the clumping. Administering oxygen will improve the pain and increase the oxygen saturation of body tissues. 3. Morphine sulfate is a narcotic for pain, but it should be given after another intervention to address the hypoxia present in sickle-cell crisis. 4. A full-body assessment, including peripheral pulses, is important to identify the location of the potential obstruction, but this is secondary to treating the hypoxia that is known to be present in sickle-cell crisis. Page Ref: 1170 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

3 ..

4) After several doses of chemotherapy, a patient complains of fatigue, pallor, progressive weakness, exertional dyspnea, headache, and tachycardia. Which problem should the nurse identify as a priority for this patient? 1. Change in nutritional status 2. Difficulty with activity 3. Feeling unable to control the disease process 4. Psychosocial issues dealing with the disease process Answer: 2 Explanation: 1. Nutritional or iron deficiency is not the cause of the symptoms, which are related to tissue hypoxia. 2. Fatigue, pallor, weakness, dyspnea with activity, headache, and tachycardia would cause difficulty with activity. 3. These manifestations do not indicate that the patient feels unable to control the disease process. 4. Although the patient might be having coping issues, the physical symptoms are the greatest complaints; therefore, coping is not the top priority in planning care. Physiological needs must be met prior to self-actualization needs. Page Ref: 1169 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with hematologic disorders.

4 ..

5) The nurse instructs a patient on the dietary management of iron deficiency anemia. Which patient statement indicates a need for additional teaching? 1. "I will eat more fruits and vegetables, especially green leafy ones, to get more B12 in my diet." 2. "I will take vitamins with extra iron in addition to eating a balanced diet with meat to correct my anemia." 3. "I will add food high in vitamin C to improve my absorption of iron in both my vitamins." 4. "I will need to include more protein foods in my diet such as meats, dried beans, and wholegrain bread." Answer: 1 Explanation: 1. The patient has an iron deficiency. Fruits and vegetables provide vitamin B 12 and folic acid but do not address the iron deficiency. 2. The lack of iron is the problem that needs to be addressed. This statement is correct. 3. The lack of iron is the problem that needs to be addressed. This statement is correct. 4. The lack of iron is the problem that needs to be addressed. This statement is correct. Page Ref: 1172 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

5 ..

6) A patient diagnosed with acute myeloid leukemia (AML) has an absolute neutrophil count of 200. What action by the nurse would minimize the risk of complications from neutropenia? 1. Using strict aseptic technique when performing all procedures 2. Spacing frequent meals throughout the day to increase caloric intake 3. Restricting fluids and salts to reduce edema 4. Regulating the thermostat for a cooler environment Answer: 1 Explanation: 1. AML results in neutropenia, which leads to increased risk for infection. Actions to minimize these risks include using strict hand hygiene to prevent possible crosscontamination. 2. Weight loss is a symptom of chronic myeloid leukemia (CML), not AML. Therefore, dietary intake is not increased with AML. 3. The patient with AML does not have a problem with fluid shifts or edema that would require these restrictions. Fluids are encouraged to remove wastes that occur with chemotherapy treatment and cellular breakdown. 4. Heat intolerance is a symptom of chronic myeloid leukemia (CML), not AML. Page Ref: 1186 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

6 ..

7) A patient recently diagnosed with chronic myeloid leukemia (CML) says he does not want to leave the spouse alone with all the household finances. Which response should the nurse refrain from making at this time? 1. "I would encourage you to discuss your feelings with your spouse to participate in the decision-making process." 2. "I would like to make a referral for you and your spouse to a support group that may be helpful with some of the issues you are having." 3. "It must be very difficult for you to think of your spouse having to be alone with the household decisions." 4. "You had better get your affairs in order now before it is too late." Answer: 4 Explanation: 1. Anticipatory grieving is identifying emotional losses or potential losses such as function, independence, appearance, friends, self-esteem, and self, prior to actual events related to death. 2. Making referrals for support or bereavement groups is appropriate at this time. 3. Leading questions encourage patients to verbalize their feelings. 4. Once the patient has expressed a concern about getting affairs "in order," the nurse can offer additional information or discuss available resources. Page Ref: 1188 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.B.7. Initiate effective treatments to relieve pain and suffering in light of patient values, preferences and expressed needs | AACN Essentials Competencies: IX.6. Implement patient and family care around resolution of end-of-life and palliative care issues, such as symptom management, support of rituals, and respect for patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

7 ..

8) The nurse determines that a patient with heparin-induced thrombocytopenia is at risk for bleeding. Which intervention should the nurse include in this patient's plan of care? 1. Avoid invasive procedures, such as rectal temperatures, urinary catheterizations, and parenteral injections. 2. Apply pressure to puncture sites for 3-5 minutes for arterial blood gases aspiration. 3. Give enemas to help the patient avoid straining during bowel movements. 4. Encourage the patient to brush the teeth thoroughly and rinse with alcohol-based mouthwash after each meal. Answer: 1 Explanation: 1. With bleeding disorders, any trauma carries the risk of extensive bleeding from platelet agglutination, due to removal of platelets by phagocytosis. 2. Arterial puncture sites require holding 15-20 minutes, and venous punctures require 3-5 minutes to make sure a clot has formed in the patient with a prolonged clotting time. 3. An enema is an invasive procedure, and the risk of bleeding from trauma is increased. The patient should be provided with stool softeners to avoid straining during a bowel movement. 4. Brisk tooth-brushing and alcohol-based mouthwash are too strong for this patient, can lead to bleeding of the gums, and are not recommended. Page Ref: 1204 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

8 ..

9) A family member is identified as a donor for a patient's stem cell transplant. What should the family member learn about this procedure? Select all that apply. 1. Peripheral blood is removed. 2. Blood is removed from a central catheter. 3. White blood cells are added to the donor's blood. 4. A strict diet of low protein and fat must be consumed. 5. Hematopoietic growth factors will be administered for 4 to 5 days before the harvesting. Answer: 1, 5 Explanation: 1. Peripheral blood is removed for the transplant. 2. The patient will receive the transplant through a central line. 3. The donor's white blood cells are used for the transplant. 4. The donor does not need to consume a specific diet that reduces protein and fat. 5. Prior to harvesting, hematopoietic growth factors, including G-CSF and GM-CSF, are administered to the donor for 4 to 5 days. This increases the concentration of stem cells in peripheral blood, allowing it to be used for the transplant. Page Ref: 1184 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

9 ..

10) Upon analysis, a patient's red blood cells (RBCs) appear microcytic and hypochromic. For which type of anemia should the nurse plan care for this patient? 1. Iron deficiency 2. Acute blood loss 3. Chronic blood loss 4. Vitamin B12 deficiency Answer: 3 Explanation: 1. Iron deficiency anemia results in a fewer number of RBCs being produced. 2. Acute blood loss anemia would result in a low level of RBCs in circulation. 3. Chronic blood loss depletes iron stores as red blood cell (RBC) production attempts to maintain the RBC supply. The resulting RBCs are microcytic (small) and hypochromic (pale). 4. With vitamin B12 deficiency anemia, the RBCs that are produced are macrocytic (large) and misshapen (oval rather than concave). Page Ref: 1162 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with hematologic disorders.

10 ..

11) A patient with chronic gastritis is experiencing tingling in the hands. Which health problem should the nurse suspect is occurring with this patient? 1. Iron deficiency anemia 2. Acute blood loss anemia 3. Folic acid deficiency anemia 4. Vitamin B12 deficiency anemia Answer: 4 Explanation: 1. Tingling hands are not directly related to iron deficiency anemia. 2. Tingling hands are not directly related to acute blood loss anemia. 3. Tingling hands are not directly related to folic acid anemia. 4. Because vitamin B12 is important for neurologic function, paresthesias develop in the extremities. Page Ref: 1164 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

11 ..

12) The nurse is caring for a patient in sickle cell crisis. For which reason should the nurse suspect this patient is experiencing edema in the hands and feet? 1. Fluid overload 2. Poor venous return 3. Small vessel infarction 4. Dehydration Answer: 3 Explanation: 1. Fluid overload is not the likely cause of the swelling. 2. Poor venous return is not the likely cause of swelling. 3. A vasoocclusive or thrombotic crisis occurs when sickling develops in the microcirculation. Obstruction of blood flow triggers vasospasm that halts all blood flow in the vessel. Lack of blood flow leads to tissue ischemia and infarction. Infarction of small vessels in the extremities causes painful swelling of the hands and feet; large joints also may be affected. 4. Dehydration is not the likely cause of swelling. Page Ref: 1165 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

12 ..

13) A patient is being treated for acquired hemolytic anemia. Which assessment finding suggests that the health problem is severe? 1. Misshapen limbs due to pathological fractures 2. Enlarged spleen 3. Jaundice 4. Bradycardia Answer: 1 Explanation: 1. The manifestations of acquired hemolytic anemia depend on the extent of hemolysis and the body's ability to replace destroyed red blood cells (RBCs). When the condition is severe, bone marrow expands, and bones may be deformed or may develop pathologic fractures. 2. An enlarged spleen may be present but is not a defining characteristic of severe acquired hemolytic anemia. 3. Jaundice may be present but is not a defining characteristic of severe acquired hemolytic anemia. 4. Bradycardia is not related to this condition. Tachycardia would be anticipated in the severe form of this anemia. Page Ref: 1169 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

13 ..

14) At the completion of a physical examination, the nurse suspects that a patient is experiencing thalassemia. What did the nurse assess to make this clinical decision? Select all that apply. 1. Confusion 2. Muscle cramps 3. Slight splenomegaly 4. Bronze skin coloring 5. Spontaneous fractures Answer: 3, 4 Explanation: 1. Confusion is not a manifestation of thalassemia. 2. Muscle cramps are not associated with thalassemia. 3. People with thalassemia minor often are asymptomatic. When manifestations do occur, they include mild splenomegaly. 4. People with thalassemia minor often are asymptomatic. When manifestations do occur, they include bronze skin coloring. 5. Spontaneous fractures are not associated with thalassemia. Page Ref: 1167 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

14 ..

15) The nurse is providing dietary instructions to a vegetarian patient with iron deficiency anemia. What should be included in these instructions? 1. Consider adding animal sources of iron and protein to the diet. 2. Ensure an adequate intake of vitamin C when consuming non-animal-based proteins. 3. Drink at least 12 glasses of water every day. 4. Avoid exercise at least 30 minutes after completing a meal or snack. Answer: 2 Explanation: 1. Suggesting animal sources of iron and protein for a vegetarian patient would not be appropriate. 2. Heme iron makes up about one-half of the iron from animal sources. Nonheme iron includes the remaining iron from animal sources and all the iron from plants, legumes, and nuts. Absorption of nonheme iron is enhanced by vitamin C and inhibited by tea and coffee. 3. Water consumption would have no bearing on this issue. 4. Physical activity would have no bearing on this issue. Page Ref: 1172 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

15 ..

16) A patient is prescribed an oral iron preparation. What should the nurse instruct this patient about this medication? Select all that apply. 1. Take the medication with orange juice. 2. Nausea is expected with this medication. 3. Take the medication with an antacid. 4. Take the medication 2 hours before a scheduled tetracycline dose. 5. Take the medication with a vitamin E supplement. Answer: 1, 4 Explanation: 1. Iron preparations should be taken with orange juice to enhance absorption. 2. Nausea, diarrhea, and constipation are manifestations of iron toxicity. 3. The patient should avoid the use of drugs that might interact with iron such as antacids. 4. If the patient is also taking tetracycline, the iron should be taken 2 hours before the tetracycline (iron reduces the absorption of tetracycline). 5. The patient should avoid the use of drugs that might interact with iron, such as vitamin E. Page Ref: 1171 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

16 ..

17) The nurse is planning to instruct a patient with secondary polycythemia about ways to prevent blood stasis. What should be included in these instructions? 1. Leg pain is normal. 2. Elevate feet and legs when sitting. 3. Restrict fluids. 4. Black stools are to be expected. Answer: 2 Explanation: 1. The patient should be instructed to report manifestations of thrombosis such as leg or calf pain. 2. Measures to prevent blood stasis include elevating the legs and feet when sitting, using support stockings, and continuing treatment measures. 3. The patient and family should be taught the importance of maintaining adequate hydration and increasing fluid intake during hot weather and when exercising. 4. The patient should be instructed to report bleeding manifested as black, tarry stools and vomiting blood or coffee-ground emesis. Page Ref: 1178 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

17 ..

18) A patient diagnosed with leukemia says, "If I have too many white blood cells, and white blood cells fight infections, why do I have to be careful not to be exposed to germs?" What would be an appropriate response for the nurse? 1. "With leukemia, you have the wrong kind of white blood cells." 2. "That's not what leukemia is." 3. "The white blood cells with leukemia aren't effective at fighting infections." 4. "Your bone marrow can become infected." Answer: 3 Explanation: 1. The cells are not "wrong" but rather not the right type at the right level to fight infection. 2. Leukemic cells are not effective in the normal immune functions of white blood cells (WBCs), and that increases the risk for infection. 3. The patient has a basic understanding of the diagnosis and simply needs clarification. 4. The risk is not of bone marrow infection but of overall systemic infection. Page Ref: 1178 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

18 ..

19) An adolescent patient has edematous lymph nodes and headaches. Which health problem should the nurse suspect is occurring with this patient? 1. Acute lymphocytic leukemia (ALL) 2. Chronic lymphocytic leukemia (CLL) 3. Acute myeloid leukemia (AML) 4. Chronic myeloid leukemia (CML) Answer: 1 Explanation: 1. Lymphocytic leukemias infiltrate the spleen, lymph nodes, CNS, and other tissues. Acute lymphocytic leukemia is the most common type of leukemia in children and young adults. 2. Chronic lymphocytic leukemia (CLL) does not have these manifestations. 3. Acute myeloid leukemia (AML) does not have these manifestations. 4. Chronic myeloid leukemia (CML) does not have these manifestations. Page Ref: 1182 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

19 ..

20) A patient who is undergoing treatment for leukemia is scheduled for a bone marrow transplant. In which phase of treatment is this patient? 1. Induction 2. Maintenance 3. Rehabilitative 4. Postremission Answer: 4 Explanation: 1. Induction does not include a bone marrow transplant. 2. Maintenance does not include a bone marrow transplant. 3. The rehabilitative phase does not include a bone marrow transplant. 4. Once remission has been achieved, postremission chemotherapy is continued to eradicate any additional leukemic cells, prevent relapse, and prolong survival. A single chemotherapeutic agent, combination therapy, or bone marrow transplant may be used for postremission treatment. Page Ref: 1184 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

20 ..

21) The nurse is preparing an analgesic for a patient with leukemia. Which route is preferred for this patient? 1. Intramuscular 2. Intravenous 3. Oral 4. Subcutaneous Answer: 3 Explanation: 1. A patient with leukemia is prone to developing infections as well as possible blood coagulation abnormalities. Administration of an analgesic through a route that would penetrate the skin could lead to bleeding or infection at the insertion site. 2. A patient with leukemia is prone to developing infections as well as possible blood coagulation abnormalities. Administration of an analgesic through a route that would penetrate the skin could lead to bleeding or infection at the insertion site. 3. The oral route is the route of choice for administering an analgesic to this patient. 4. A patient with leukemia is prone to developing infections as well as possible blood coagulation abnormalities. Administration of an analgesic through a route that would penetrate the skin could lead to bleeding or infection at the insertion site. Page Ref: 1186 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

21 ..

22) A patient is diagnosed with stage II Hodgkin lymphoma. How should the nurse interpret the extent of this patient's illness? 1. A single lymph node with systemic symptoms 2. Two or more lymph nodes on the same side of the diaphragm 3. Upper abdominal lymph nodes without systemic symptoms 4. An extranodal site involvement with systemic symptoms Answer: 2 Explanation: 1. Involvement of a single lymph node with systemic symptoms is stage I. 2. In stage II, the disorder involves two or more lymph node regions on the same side of the diaphragm. 3. Involvement of upper abdominal lymph nodes without systemic symptoms is stage III1. 4. Involvement of an extranodal site with systemic symptoms is stage IV. Page Ref: 1192 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.3 Describe the pathophysiology and manifestations of lymphoid tissue disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

22 ..

23) A college-age patient who is in the hospital for treatment for Hodgkin disease is visited by friends who bring a pizza and cola. What should the nurse do to ensure the patient's comfort? 1. Ask the visitors to leave. 2. Ask the visitors to eat the pizza in the lounge. 3. Encourage the patient to eat as much pizza as possible. 4. Provide the patient with an antiemetic and suggest something else for the patient to eat with the visitors. Answer: 4 Explanation: 1. Asking the visitors to leave would be excluding the patient from an enjoyable social activity. 2. Having the visitors eat in the lobby would be excluding the patient from an enjoyable social activity. 3. Allowing the patient to eat as much as desired without addressing any current nausea would not be most helpful to the patient. 4. The effects of malignant lymphoma and its treatment with chemotherapy and/or radiation therapy can contribute to nausea and interfere with nutritional status. Nausea, a sensation of abdominal fullness, and fear of vomiting often limit food intake. Crackers and hard candy often relieve queasiness, whereas hot, spicy, sweet, or strong-smelling foods may increase nausea. Alternative nausea relief measures may be effective. Page Ref: 1195 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 33.3 Describe the pathophysiology and manifestations of lymphoid tissue disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

23 ..

24) A patient with idiopathic thrombocytopenia purpura continues to experience symptoms of the disease after completing several courses of prednisone therapy. Which treatment will most likely be recommended for this patient? 1. Lifelong prednisone therapy 2. Splenectomy 3. Aspirin therapy 4. Weekly platelet transfusions Answer: 2 Explanation: 1. Lifelong prednisone therapy is rarely prescribed and prednisone therapy has already proven ineffective for this patient. 2. A splenectomy is the treatment of choice if the patient with idiopathic thrombocytopenia purpura relapses when glucocorticoids are discontinued. The spleen is the site of platelet destruction and antibody production. This surgery often cures the disorder, although relapse may occur years after splenectomy. 3. Aspirin therapy would likely result in bleeding and would be contraindicated in this situation. 4. Platelet transfusions are ineffective with this disorder because the problem is that platelets are being produced adequately but are destroyed. Page Ref: 1203 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

24 ..

25) A patient with hemophilia is admitted with acute bleeding. Until the cause of the bleeding is determined, which intervention should the nurse anticipate for the patient? 1. Infusing packed red blood cells 2. Infusing normal saline 3. Infusing heparin 4. Infusing fresh-frozen plasma Answer: 4 Explanation: 1. Red packed cells would increase volume but would not replace the clotting factors. 2. Normal saline would increase volume but would not replace the clotting factors. 3. Heparin would be contraindicated as it would promote further bleeding. 4. Fresh-frozen plasma replaces all clotting factors except platelets. When the cause of bleeding is not yet determined, fresh-frozen plasma may be administered intravenously until a definitive diagnosis is made. Page Ref: 1206 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

25 ..

26) A patient with disseminated intravascular coagulation (DIC) is not responding to infusions of fresh-frozen plasma and platelets. Which intervention might be indicated for this patient? Select all that apply. 1. Heparin injections 2. Heparin infusion 3. Factor VIII infusion 4. Normal saline infusion 5. Bone marrow biopsy Answer: 1, 2 Explanation: 1. When bleeding is the major manifestation of DIC, fresh-frozen plasma and platelet concentrates are given to restore clotting factors and platelets. Heparin may be administered. Heparin interferes with the clotting cascade and may prevent further clotting factor consumption due to uncontrolled thrombosis. It is used when bleeding is not controlled by plasma and platelets, as well as when the patient has manifestations of thrombotic problems such as acrocyanosis and possible gangrene. 2. Long-term heparin therapy, by injection or continuous infusion with a portable pump, may be necessary for patients with chronic DIC. 3. Factor VIII is not useful for this patient. 4. Normal saline would not help with the clotting. 5. The diagnosis has already been determined, and bone marrow aspiration would not be indicated. Page Ref: 1210 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

26 ..

27) A patient who is undergoing chemotherapy for lymphoma says, "I thought I was ugly before this all started. Now I know for sure I'm disgusting to look at." What is this patient most at risk for developing related to these comments? 1. Changed body image perception 2. Reduced sexual response 3. Altered taste sensation 4. Inability to cope with the diagnosis and treatment Answer: 1 Explanation: 1. Radiation and chemotherapy lead to changes in appearance and body function, further altering body image. Reactions to this diagnosis vary and may include refusal to look in a mirror or discuss the effects of the disease or treatment, unwillingness to participate in rehabilitation, inappropriate treatment decisions, increasing dependence on others or refusal to provide self-care, hostility, withdrawal, and signs of grieving. 2. Although altered sexual response may occur, the patient has not identified it as a current problem. 3. The patient has not identified an alteration in taste. 4. The patient has not indicated lack of coping with the diagnosis or treatment. Page Ref: 1195 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.3 Describe the pathophysiology and manifestations of lymphoid tissue disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

27 ..

28) A patient who is being treated for malignant lymphoma is experiencing pruritus. What intervention would be appropriate for this patient? Select all that apply. 1. Bathing with cool water 2. Vigorously rubbing the skin after bathing 3. Applying lavender-scented body lotion 4. Keeping the room temperature above normal 5. Cleansing bedding and clothing in mild detergent with a second rinse cycle Answer: 1, 5 Explanation: 1. The nurse should teach the patient to use cool water to reduce itching. 2. The patient should avoid vigorous rubbing of the skin and blot dry instead. 3. Plain cornstarch is preferred over perfumed lotions. 4. Patient rooms should be cool with adequate humidity. The nurse should instruct the patient to use lightweight bedding and clothing. 5. To reduce pruritus, bedding should be washed in mild detergent and put through a second rinse cycle. Page Ref: 1196 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 33.3 Describe the pathophysiology and manifestations of lymphoid tissue disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

28 ..

29) The nurse suspects that a patient being treated with deferoxamine (Desferal) is experiencing adverse effects of the medication. What did the nurse assess to come to this conclusion? Select all that apply. 1. Urticaria 2. Ecchymosis 3. Upper body rash 4. Pink urine 5. Blood in the stool Answer: 1, 3 Explanation: 1. Deferoxamine (Desferal) is relatively safe, although urticaria may develop. 2. Ecchymosis is not an adverse effect of this medication. 3. Deferoxamine (Desferal) is relatively safe, although local skin reactions such as rash may develop. 4. Pink urine is not an adverse effect of this medication. 5. Blood in the stool is not an adverse effect of this medication. Page Ref: 1176 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

29 ..

30) A patient has developed folic acid deficiency anemia. The nurse notes that the patient weighed 52.72 kilograms 1 year ago and weighs 44.23 kilograms today. Calculate the patient's weight loss in pounds. Round to the nearest tenth decimal place. Answer: 18.7 Explanation: This patient lost 8.49 kilograms of weight. There are 2.2 lbs. in each kilogram. The patient lost 18.678 lbs., rounded to 18.7 lbs. Page Ref: 1164 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

30 ..

31) A patient with polycythemia vera is admitted for treatment. What should the nurse expect to be prescribed for this patient? Select all that apply. 1. Aspirin 2. Antibiotics 3. Phlebotomy 4. Hydroxyurea 5. Antihistamines Answer: 1, 3, 4, 5 Explanation: 1. One 325-mg aspirin tablet daily may be ordered to control thrombosis without increasing the risk of bleeding. 2. Antibiotics are not indicated in the treatment of polycythemia vera. 3. Patients with polycythemia benefit from periodic phlebotomy to keep blood volume and viscosity within normal levels. 4. Chemotherapeutic agents such as hydroxyurea may be used to suppress marrow function. 5. Pruritus may be relieved with antihistamines. Page Ref: 1178 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.1 Describe the pathophysiology and manifestations of red blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

31 ..

32) A patient with multiple ecchymoses and occult blood in the stool has a decreased level of Factor VIII. Which should the nurse expect for this patient? Select all that apply. 1. Normal platelet count 2. Elevated prothrombin time 3. Diagnosis of hemophilia B 4. Administer fresh-frozen plasma as prescribed 5. Bleeding time within normal limits Answer: 1, 4, 5 Explanation: 1. The patient has likely developed hemophilia A. With this condition, the serum platelet count is within normal limits. The patient would commonly receive fresh-frozen plasma. 2. The patient's prothrombin time will be within normal limits. 3. The patient has more likely developed hemophilia A. Type B hemophilia is characterized by a deficiency of factor IX. 4. The patient would commonly receive fresh-frozen plasma. 5. The patient's bleeding time will likely be within normal limits. Page Ref: 1205-1206 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with hematologic disorders.

32 ..

33) The nurse teaches to the spouse and patient with Hodgkin disease about the disease process. Which patient statement indicates the need for further education? Select all that apply. 1. "The physician is ordering radiation therapy for me." 2. "My white blood cell count was low and my red blood cell count was high, and that helped the physician diagnose me." 3. "The doctor has classified my Hodgkin disease as stage III because I have involved lymph nodes in my liver and in my spleen." 4. "One out of every four patients without symptoms of Hodgkin disease dies of this disease." 5. "Because I had a heart attack in the past, the physician will probably prescribe rituximab for me." Answer: 2, 3, 5 Explanation: 1. Many lymphomas are highly responsive to radiation, so this would be an appropriate method of treatment. 2. The CBC of a patient with Hodgkin disease often shows that the patient has a mild case of anemia and leukocytosis. 3. With stage III lymphoma, there is involvement of lymph node regions or structures above and below the diaphragm. The situation described is more characteristic of stage II lymphoma. 4. Three of every four patients without systemic symptoms achieve complete remission. 5. Rituximab should be used cautiously in patients who have a history of cardiac disorders. Page Ref: 1192-1193 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 33.3 Describe the pathophysiology and manifestations of lymphoid tissue disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with hematologic disorders.

33 ..

34) A patient with acute lymphocytic leukemia will be starting chemotherapy. For which medication should the patient receive teaching? Select all that apply. 1. Prednisone 2. Cytarabine (Cytoxan) 3. Vincristine (Oncovin) 4. Asparaginase (Elspar) 5. Daunorubicin (Cerubidine) Answer: 1, 3, 4, 5 Explanation: 1. The chemotherapeutic regimen for acute lymphocytic leukemia includes prednisone. 2. Cytarabine (Cytoxan) is used to treat acute myeloid leukemia. 3. The chemotherapeutic regimen for acute lymphocytic leukemia includes vincristine (Oncovin), a plant alkaloid. 4. The chemotherapeutic regimen for acute lymphocytic leukemia includes asparaginase (Elspar). 5. The chemotherapeutic regimen for acute lymphocytic leukemia includes daunorubicin (Cerubidine), an antitumor antibiotic. Page Ref: 1183 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with hematologic disorders.

34 ..

35) After completing a medication history, the nurse is concerned that a patient is at risk for secondary thrombocytopenia. Which medication did the nurse learn that the patient takes that increases this risk? Select all that apply. 1. Digoxin 2. Warfarin 3. Penicillin 4. Cimetidine 5. Furosemide Answer: 1, 4, 5 Explanation: 1. Medications identified as causing secondary thrombocytopenia include digoxin. 2. Warfarin is not identified as a medication that causes secondary thrombocytopenia. 3. Penicillin is not identified as a medication that causes secondary thrombocytopenia. 4. Medications identified as causing secondary thrombocytopenia include cimetidine. 5. Medications identified as causing secondary thrombocytopenia include furosemide. Page Ref: 1202 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with hematologic disorders.

35 ..

36) While reviewing preoperative orders, the nurse notes that a patient is prescribed desmopressin acetate (DDAVP). For which health problem should the nurse plan care? Select all that apply. 1. Hemophilia A 2. Mononucleosis 3. Iron deficiency anemia 4. von Willibrand disease 5. Heparin-induced thrombocytopenia Answer: 1, 4 Explanation: 1. Desmopressin acetate (DDAVP) may be given to people with mild hemophilia A prior to minor surgeries. 2. Desmopressin acetate (DDAVP) is not used to treat mononucleosis. 3. Desmopressin acetate (DDAVP) is not used to treat iron deficiency anemia. 4. Desmopressin acetate (DDAVP) may be given to people with von Willebrand disease prior to minor surgeries. 5. Desmopressin acetate (DDAVP) is not used to treat heparin-induced thrombocytopenia. Page Ref: 1206 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 33.4 Describe the pathophysiology and manifestations of platelet and coagulation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with hematologic disorders.

36 ..

37) After reviewing laboratory results, the nurse is concerned that a patient being treated for leukemia is developing tumor lysis syndrome. What did the nurse assess to make this clinical decision? Select all that apply. 1. Hyperkalemia 2. Hyponatremia 3. Hypocalcemia 4. Hypermagnesemia 5. Hyperphosphatemia Answer: 1, 3, 5 Explanation: 1. Tumor lysis syndrome is a risk in patients with leukemia who are undergoing their initial treatment with chemotherapy. Tumor lysis syndrome develops when a large number of malignant cells are destroyed by treatment with chemotherapy or radiation. The resultant by-products of cell lysis can overwhelm the body's ability to effectively eliminate them, leading to hyperkalemia. 2. Hyponatremia does not occur in tumor lysis syndrome. 3. Tumor lysis syndrome is a risk in patients with leukemia who are undergoing their initial treatment with chemotherapy. Tumor lysis syndrome develops when a large number of malignant cells are destroyed by treatment with chemotherapy or radiation. The resultant byproducts of cell lysis can overwhelm the body's ability to effectively eliminate them, leading to secondary hypocalcemia. 4. Hypermagnesemia does not occur with tumor lysis syndrome. 5. Tumor lysis syndrome is a risk in patients with leukemia who are undergoing their initial treatment with chemotherapy. Tumor lysis syndrome develops when a large number of malignant cells are destroyed by treatment with chemotherapy or radiation. The resultant byproducts of cell lysis can overwhelm the body's ability to effectively eliminate them, leading to hyperphosphatemia. Page Ref: 1187 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 33.2 Describe the pathophysiology and manifestations of white blood cell disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with hematologic disorders.

37 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 34 Assessing the Respiratory System 1) The nurse observes a patient breathing through an open mouth. Which function is being bypassed by mouth breathing? 1. Cooling the air 2. Neutralizing the air 3. Filtering the air 4. Separating the air Answer: 3 Explanation: 1. The mucosa is highly vascular, warming air that moves across its surface. Cooling of the air would not be happening with nasal breathing. 2. The air would not be neutralized or separated with nasal breathing, so it is not being bypassed with mouth breathing. 3. The nasal hairs filter the air as it enters the nares. The rest of the cavity is lined with mucous membranes that contain olfactory neurons and goblet cells that secrete thick mucus. The mucus not only traps dust and bacteria but also contains lysozyme, an enzyme that destroys bacteria as they enter the nose. As mucus and debris accumulate, mucosal ciliated cells move it toward the pharynx, where it is swallowed. 4. The air would not be neutralized or separated with nasal breathing, so it is not being bypassed with mouth breathing. Page Ref: 1217 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

1 ..

2) The nurse notes that a patient with a head cold has a change in speech tone and volume. What should the nurse consider as being the reason for this observation? 1. The patient has been sneezing because of the cold. 2. The patient has been coughing because of the cold. 3. The cold is raising the patient's body temperature. 4. The sinuses play a role in speech. Answer: 4 Explanation: 1. Sneezing does not affect speech. 2. Coughing does not affect speech. 3. There is no evidence that the patient has a fever. 4. Sinuses lighten the skull, assist in speech, and produce mucus that drains into the nasal cavities to help trap debris. Page Ref: 1217 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

2 ..

3) A patient is diagnosed with a middle ear infection. Which portion of the patient's airway is affected? 1. Nasopharynx 2. Oropharynx 3. Laryngopharynx 4. Nares Answer: 1 Explanation: 1. The eustachian tubes also open into the nasopharynx, and connect it with the middle ear. This is the opening from the nasal passages to the back of the throat. 2. The oropharynx is the mouth-to-throat location. 3. The laryngopharynx is the area from the back of the throat to the deeper part of the throat. 4. Nares are the openings that enter the nose. Page Ref: 1217 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

3 ..

4) The nurse prepares to assess a patient's respiratory system. Which structure should the nurse use to locate the approximate position of the larynx? 1. Clavicle 2. Adam's apple 3. First rib 4. Shoulder joint Answer: 2 Explanation: 1. The clavicle is not near the location of the larynx. 2. The thyroid cartilage is formed by the fusion of two cartilages; the fusion point is visible as the Adam's apple. 3. The first rib is not near the location of the larynx. 4. The shoulder joint is not near the location of the larynx. Page Ref: 1218 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.

4 ..

5) During an assessment, a patient begins to cough. What should the nurse realize about this finding? 1. The patient has a cold. 2. The patient is nervous. 3. Something other than air was entering the larynx. 4. Something other than air was entering the epiglottis. Answer: 3 Explanation: 1. The coughing does not necessarily mean that the patient has a cold. 2. Being nervous is not typically associated with coughing. 3. If anything other than air enters the larynx, a cough reflex expels the foreign substance before it can enter the lungs. 4. The epiglottis is a valve-like piece of tissue, and nothing can enter it. Page Ref: 1218 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

5 ..

6) A patient's blood oxygen saturation level is 99% on room air. Which structure should the nurse identify that transports oxygenated blood to the heart? 1. Pulmonary arteries 2. Pulmonary veins 3. Bronchial arteries 4. Bronchial veins Answer: 2 Explanation: 1. The vascular system of the lungs consists of the pulmonary arteries, which deliver blood to the lungs for oxygenation. 2. The pulmonary veins deliver oxygenated blood to the heart. 3. Bronchial arteries and are located within the lungs and are not directly involved with transporting oxygenated blood to the heart. 4. Bronchial veins are located within the lungs and are not directly involved with transporting oxygenated blood to the heart. Page Ref: 1219 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

6 ..

7) A patient is demonstrating poor exhalation. Which health problem is this patient at risk for developing? 1. Pleurisy 2. Pulmonary edema 3. Increased carbon dioxide levels 4. Reduced oxygen capacity of red blood cells Answer: 3 Explanation: 1. Pleurisy is pain upon inspiration. 2. Pulmonary edema may accumulate as a result of poor inhalation, not exhalation. 3. During expiration, the carbon dioxide is expelled. If the patient cannot exhale effectively, carbon dioxide can build up. 4. Poor exhalation does not have an effect on the oxygen carrying capacity of red blood cells. Page Ref: 1223 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

7 ..

8) During the assessment of a patient's respiratory status, the nurse locates the manubrium and the body of the sternum. Which anatomical structure is the nurse assessing? 1. Adam's apple 2. Angle of Louis 3. Intercostal space 4. Xiphoid process Answer: 2 Explanation: 1. The Adam's apple is located on the larynx. 2. The junction between the manubrium and the body of the sternum is called the manubriosternal junction, or the angle of Louis. 3. Intercostal space refers to the space between the ribs. 4. The xiphoid process is on the end tip of the sternum. Page Ref: 1220 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.

8 ..

9) During pulmonary function tests, a patient is found to have approximately 500 mL of air moving in and out of the lungs during normal quiet breathing. What should the finding be considered? 1. Tidal volume 2. Expiratory reserve volume 3. Residual volume 4. Vital capacity Answer: 1 Explanation: 1. Tidal volume (TV) is the amount of air (approximately 500 mL) that is moved in and out of the lungs with each normal, quiet breath. 2. Expiratory reserve volume (ERV) is the approximately 1000 mL of air that can be forced out over the tidal volume. 3. The residual volume is the volume of air (approximately 1100 mL) that remains in the lungs after a forced expiration. 4. Vital capacity (VC) refers to the sum of TV + IRV + ERV and is approximately 4500 mL in the healthy patient. Page Ref: 1220 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

9 ..

10) During the assessment of a patient's respiratory status, the nurse observes the expiration phase as being almost twice as long as the inspiration phase. What is this finding associated with? 1. Chronic lung disease 2. Heart failure 3. Respiratory distress 4. Normal respiration Answer: 4 Explanation: 1. This finding does not suggest chronic lung disease. 2. This finding does not suggest heart failure. 3. This finding does not suggest respiratory distress. 4. During normal respiration, a single inspiration lasts for about 1 to 1.5 seconds, whereas an expiration lasts for about 2 to 3 seconds. Page Ref: 1221 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

10 ..

11) The nurse counts a patient's respirations at 30 per minute. From this finding, what about the patient's respiratory status should cause the nurse concern? 1. Pneumonia is developing. 2. Increased carbon dioxide in the blood is being expelled. 3. Respiratory arrest is beginning. 4. Pain is affecting the respiratory rate. Answer: 2 Explanation: 1. There is not enough data provided to indicate pneumonia. 2. When carbon dioxide concentration in the blood increases or the pH decreases, the respiratory rate increases. 3. With respiratory arrest the respirations would typically be decreased. 4. There is not enough information to determine if the patient is experiencing pain. Page Ref: 1221 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

11 ..

12) A patient is diagnosed with a low iron count. For which potential health problem should the nurse assess this patient? 1. Increased carbon dioxide in the blood 2. Nausea 3. Anxiety 4. Poor tissue oxygenation Answer: 4 Explanation: 1. A low iron count is not caused by increased carbon dioxide in the blood. 2. Nausea is not generally associated with low iron count. 3. Anxiety is not generally associated with low iron count. 4. Oxygen is carried in the blood either bound to hemoglobin or dissolved in the plasma. Oxygen is not very soluble in water, so almost all oxygen that enters the blood from the respiratory system is carried to the cells of the body by hemoglobin. Page Ref: 1222 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.

12 ..

13) During the assessment of a patient's nasal cavities, the nurse notes watery nasal discharge and pale turbinates. These findings are consistent with what health problem? 1. Allergies 2. Infection 3. Cocaine use 4. Sinus infection Answer: 1 Explanation: 1. Allergies may be indicated by watery nasal drainage, pale turbinates, and polyps on the turbinates. 2. Drainage from an infection would be colored and thicker. 3. Perforation of the septum may occur with chronic cocaine abuse. 4. Drainage from a sinus infection would be colored and thicker. Page Ref: 1224 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.

13 ..

14) During a nap, the nurse notes that a patient's respirations periodically stop. How should the nurse document this finding? 1. Tachypnea 2. Bradypnea 3. Apnea 4. Atelectasis Answer: 3 Explanation: 1. Tachypnea is increased respiration. 2. Bradypnea is slow respirations. 3. Apnea is the cessation of breathing that lasts from a few seconds to a few minutes. 4. Atelectasis describes an illness, which is not evident in this situation. Page Ref: 1224 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

14 ..

15) During the palpation of a patient's chest for expansion, the nurse notices a decrease in expansion of the right side. With what health problem is this finding associated? Select all that apply. 1. Emphysema 2. Pneumonia 3. Pleural effusion 4. Heart failure 5. Pneumothorax Answer: 2, 3, 5 Explanation: 1. Bilateral chest expansion is decreased in emphysema. 2. Thoracic expansion is decreased on the affected side in pneumonia. 3. Thoracic expansion is decreased on the affected side in pleural effusion. 4. Heart failure would not result in a change in chest expansion. 5. Thoracic expansion is decreased on the affected side in pneumothorax. Page Ref: 1225 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

15 ..

16) The nurse percusses hyperresonance over a patient's lungs. With which health problem is this finding associated? 1. Pneumonia 2. Atelectasis 3. Chronic asthma 4. Pleural effusion Answer: 3 Explanation: 1. Pneumonia does not cause hyperresonance. 2. Atelectasis does not cause hyperresonance. 3. Hyperresonance is heard in patients with chronic asthma and pneumothorax. 4. Pleural effusion does not cause hyperresonance. Page Ref: 1225 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

16 ..

17) The nurse is auscultating a patient's lungs. Which breath sound should the nurse identify as abnormal? Select all that apply. 1. Crackles 2. Vesicular 3. Bronchovesicular 4. Wheezes 5. Bronchial Answer: 1, 4 Explanation: 1. Normally, there are no crackles. 2. Vesicular is considered a normal breath sound. 3. Bronchovesicular is considered a normal breath sound. 4. Normally, there are no wheezes. 5. Bronchial is considered a normal breath sound. Page Ref: 1226 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

17 ..

18) A patient is having pulmonary function tests. What should the nurse instruct the patient about the process? 1. "Expect to be sedated for the test." 2. "Anti-nausea medication will be provided prior to the test." 3. "A nose clip will be worn during the test." 4. "Oxygen will be used for a while after the test." Answer: 3 Explanation: 1. Patients are not sedated for pulmonary function testing. 2. Nausea is not a common issue with the tests. 3. A nose clip is placed on a non-sedated patient during the pulmonary function testing. 4. Oxygen is typically not needed after the test. Page Ref: 1220 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

18 ..

19) The nurse is caring for an older patient. Which age-related change increases this patient's risk for residual air volume in the lungs? 1. Elasticity of lungs decreases with age. 2. Older adults have a more rapid respiratory rate. 3. There is a tightening of the diaphragm with age. 4. Intercostal muscles become weaker with age. Answer: 4 Explanation: 1. Elasticity of the diaphragm, not necessarily of the lungs, is lost, and the diaphragm flattens, or tightens. 2. The respiratory rate of well older adults slows, not increases, with age. 3. Elasticity of the diaphragm, not necessarily of the lungs, is lost, and the diaphragm flattens, or tightens. 4. As a person ages, the intercostal muscles become weak. This reduces the movement of the chest wall. Page Ref: 1229 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.3 Differentiate considerations for assessing the respiratory system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

19 ..

20) The nurse administers oxygen to a patient who has lost a moderate amount of blood following a motor vehicle crash. What is the primary reason for this intervention? 1. Ease the work of breathing for the patient 2. Compensate for the reduction in circulating oxygen 3. Provide comfort during assessment 4. Prevent shock from developing Answer: 2 Explanation: 1. Breathing might be easier, but this is an additional benefit and not the primary reason. 2. As blood volume is lost, hemoglobin is lost. Oxygen is carried from the respiratory system to the cells by hemoglobin in the blood. 3. The patient might be more comfortable, but this is an additional benefit and not the primary reason. 4. The risk of shock might be decreased through the oxygen administration, but this is an additional benefit, and not the primary reason. Page Ref: 1222 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

20 ..

21) A patient admitted with probable emphysema is scheduled for diagnostic tests. What test should the nurse expect to be prescribed to assess the patient's acid‒base balance? 1. Bronchoscopy 2. Sputum studies 3. Pulse oximetry 4. Arterial blood gases (ABGs) Answer: 4 Explanation: 1. A bronchoscopy provides visualization of internal respiratory structures. 2. Sputum studies can provide specific information about bacterial organisms. 3. Pulse oximetry is a noninvasive test that evaluates the oxygen saturation level of blood. 4. ABGs are done to assess alterations in acid‒base balance caused by respiratory disorders, metabolic disorders, or both. Page Ref: 1227 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

21 ..

22) While preparing a patient for a bronchoscopy, the nurse ensures the suction equipment is available. Why is the nurse taking this precaution? 1. There is a high risk of a reaction to medications used for sedation. 2. Laryngospasm and respiratory distress could follow this test. 3. Suction equipment should always be available. 4. Pulmonary embolus is a complication following this test. Answer: 2 Explanation: 1. A potential reaction to medications used for anesthesia or sedation would be assessed prior to the test. 2. Anesthetics given for the procedure might suppress the cough and gag reflexes. Secretions might be difficult for the patient to expectorate without assistance. If the secretions are not removed, respiratory distress can occur. The suction equipment would be used to remove the secretions, so it must be ready to go before the procedure even starts. 3. Suction equipment does not always have to be available for every diagnostic test. 4. Pulmonary emboli development is not a commonly anticipated complication of a bronchoscopy. Page Ref: 1227 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

22 ..

23) A patient suspected of having a lung mass asks why a positron emission tomography (PET) scan was ordered instead of a computed tomography (CT) scan. What is the best response by the nurse? 1. "Your doctor prefers to order PET scans." 2. "Why are you concerned about this test?" 3. "PET scans focus on your particular problem." 4. "You will still need a CT scan also." Answer: 3 Explanation: 1. Making a personal reference to the physician is not professional. 2. The patient did not express concern about the test merely by asking the question. 3. A PET scan is used more specifically to identify lung cancers. 4. A CT scan would not typically be indicated in addition to or following a PET scan. Page Ref: 1228 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

23 ..

24) The nurse is instructing a patient on collecting a sputum sample. What is the best time for the nurse to collect this specimen? 1. After a meal 2. Upon awakening from a nap 3. Before a meal 4. Upon awakening in the morning Answer: 4 Explanation: 1. Collecting a specimen after a meal would not produce a specimen, and could induce vomiting. 2. A nap, due to the shortened time frame, is not provided the best opportunity for obtaining the specimen. 3. Before a meal would not produce the same results, and can tire a patient. 4. There is the greatest opportunity to obtain a sputum specimen in the morning. Respiratory secretions pool more during sleep. Patients with respiratory illness cough more when awakening, so sputum collection would be best before daily activities are initiated. Page Ref: 1229 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

24 ..

25) The nurse is assessing an older patient's respiratory status. What age-related change can predispose this patient to pneumonia? Select all that apply. 1. Slower respiratory rate 2. Less effective cough 3. Immobility 4. Increased pain response 5. Fixed income Answer: 2, 3 Explanation: 1. Respiratory rate does not contribute to the risk of pneumonia. 2. Skeletal muscle strength is lost in the thorax and diaphragm with aging. This contributes to a less effective cough and the ability to remove respiratory secretions. 3. The secretions can pool in the lungs if the patient is not mobile, providing an environment for pneumonia to develop. 4. It is a myth that older adults have an increased pain response, and this would not directly contribute to the development of pneumonia. 5. There is no direct correlation between being on a fixed income and developing pneumonia. Page Ref: 1229 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.3 Differentiate considerations for assessing the respiratory system of older adults, veterans, individuals in the LGBTQI population, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

25 ..

26) The nurse assesses a patient's lung sounds. For which finding should the nurse follow-up? 1. Heard crackles earlier, but now hear nothing 2. Hear wheezing in the right lobes, but clear on the left 3. Coarse crackles that clear with coughing 4. Scattered wheezes bilaterally Answer: 1 Explanation: 1. The absence of breath sounds could indicate a collapsed lung, pleural effusion, or obstruction of a primary bronchus and needs to be further evaluated. 2. Wheezing in the right lobes would not indicate immediate action. 3. Coarse crackles that clear with coughing would not indicate immediate action. 4. Scattered wheezes bilaterally would not indicate immediate action. Page Ref: 1226 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

26 ..

27) The nurse notes that a patient is susceptible to chronic pulmonary diseases. What did the nurse assess to make this clinical decision? 1. The patient owned and worked a farm. 2. The patient worked in a hospital. 3. The patient is an air traffic controller. 4. The patient played in a band. Answer: 1 Explanation: 1. Farmers are exposed to pesticides every day while they are preparing the land for farming and while crops are growing. 2. Working in a hospital may increase the risk for colds and influenza but does not increase the risk for chronic pulmonary disease. 3. Air traffic controllers are not more likely to have increased risk of chronic pulmonary disease. 4. Band members are not more likely to have increased risk of chronic pulmonary disease. Page Ref: 1224 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.

27 ..

28) The nurse is planning a class for nursing assistants. What should the nurse include as causing interference with accurate pulse oximeter readings? Select all that apply. 1. External light sources 2. Nail polish 3. Inhalation injuries 4. Arterial pulses 5. Placement on cartilage Answer: 1, 2 Explanation: 1. Other sources of light can cause inaccurate readings. 2. Nail polish on finger/toenails can cause inaccurate readings. 3. There is no evidence that inhalation injuries will alter pulse oximeter readings. 4. Arterial pulses have no influence on pulse oximeter readings. 5. The sensor can be placed on the nose or earlobe, which contains cartilage. Page Ref: 1228 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

28 ..

29) The nurse wants to assess the apex of a patient's right lung. In which location should the nurse place the stethoscope to assess this patient? 1. Intercostal space, sixth rib near the sternum 2. Intercostal space, fourth rib near the axillary line 3. Below the scapula 4. Near the right clavicle Answer: 4 Explanation: 1. This is an incorrect location. 2. This is an incorrect location. 3. The scapulae are located posterior to the lungs. 4. The apex of each lung lies just below the clavicle, whereas the base of each lung rests on the diaphragm. Page Ref: 1219 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the respiratory system.

29 ..

30) A patient is recovering from a bronchoscopy. What care should the nurse provide to this patient? Select all that apply. 1. Instruct the patient to avoid eating and drinking until the gag reflex returns. 2. Report dark blood-tinged respiratory secretions to the physician. 3. Notify the physician with any breathing difficulty. 4. Administer pain medications immediately following the procedure. 5. Instruct the patient on use of incentive spirometry to use following the procedure. Answer: 1, 3 Explanation: 1. A patient should not eat or drink until the gag reflex returns. 2. Dark-tinged blood, especially if biopsies were collected, is common after the procedure. 3. The patient should be instructed to notify the physician with any breathing difficulty. 4. There is commonly minimal discomfort following this procedure, so an immediate administration of pain medication would not be indicated. 5. Incentive spirometry is not indicated in the recovery from this procedure. Page Ref: 1227 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

30 ..

31) A patient is scheduled to have a magnetic resonance imaging scan (MRI). What information is most important for the nurse to obtain before the procedure? 1. Whether the patient is wearing any metal 2. When the patient last ate or drank 3. Whether the patient is allergic to shellfish 4. Whether the patient has any loose teeth Answer: 1 Explanation: 1. The nurse must know whether the patient is wearing any metal. 2. The patient usually does not need to change the diet before an MRI. 3. Contrast dye is not used for an MRI. 4. Dental issues do not alter the ability for an MRI to be completed. Page Ref: 1228 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the respiratory system.

31 ..

32) The nurse is preparing to assess a patient with cystic fibrosis. What should the nurse keep in mind about this patient's health problem? Select all that apply. 1. The patient will have difficulty speaking. 2. The patient will have cardiac dysrhythmias. 3. The patient is prone to respiratory infections. 4. The patient will have altered nutritional status. 5. The patient will have thick respiratory secretions. Answer: 3, 4, 5 Explanation: 1. Cystic fibrosis does not affect the ability to speak. 2. Cystic fibrosis does not affect cardiac status. 3. Cystic fibrosis is the most common fatal genetic disease in the United States today. All gene defects result in defective transport of chloride and sodium by epithelial cells. As a result, the amount of sodium chloride is increased in body secretions. Thick mucus is produced that clogs the lungs, leads to infection. 4. Cystic fibrosis is the most common fatal genetic disease in the United States today. All gene defects result in defective transport of chloride and sodium by epithelial cells. As a result, the amount of sodium chloride is increased in body secretions. Thick mucus blocks pancreatic enzymes from reaching the intestines to digest food. 5. Cystic fibrosis is the most common fatal genetic disease in the United States today. All gene defects result in defective transport of chloride and sodium by epithelial cells. As a result, the amount of sodium chloride is increased in body secretions. Thick mucus is produced that clogs the lungs. Page Ref: 1223 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

32 ..

33) The nurse notes that a patient's respiratory rate and depth constantly change. What structure should the nurse recall is affecting this patient's respirations? Select all that apply. 1. Pons 2. Aortic bodies 3. Carotid bodies 4. Medulla oblongata 5. Number of alveoli Answer: 1, 2, 3, 4 Explanation: 1. The rate and depth of respirations are controlled by respiratory centers in the pons of the brain. 2. The rate and depth of respirations are controlled by chemoreceptors located in the aortic bodies. 3. The rate and depth of respirations are controlled by chemoreceptors located in the carotid bodies. 4. The rate and depth of respirations are controlled by respiratory centers in the medulla oblongata. 5. The number of alveoli will not affect respiratory rate and depth. Page Ref: 1221 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

33 ..

34) During an assessment, the nurse becomes concerned about a patient's lung compliance. What factor about the patient's respiratory status caused the nurse to have this concern? Select all that apply. 1. Patency of the nares 2. Flexibility of the rib cage 3. Status of a sinus infection 4. Elasticity of the lung tissue 5. Pulse oximeter reading of 97% Answer: 2, 4 Explanation: 1. Patency of the nares does not affect lung compliance. 2. Lung compliance is the distensibility of the lungs. It depends on the flexibility of the rib cage. 3. A sinus infection would not affect lung compliance. 4. Lung compliance is the distensibility of the lungs. It depends on the elasticity of the lung tissue. 5. A pulse oximeter reading of 97% and does not affect lung compliance. Page Ref: 1221 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.1 Describe the anatomy, physiology, and functions of the nose and sinuses, pharynx, larynx, trachea, lungs, pleura, bronchi and alveoli, and rib cage and intercostal muscles, and identify abnormal findings that may indicate impairment of the respiratory system. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

34 ..

35) The nurse determines that a patient has bronchovesicular breath sounds. What criteria did the nurse use to make this clinical decision? Select all that apply. 1. Medium pitch 2. Heard between the scapula 3. Heard on each side of the sternum 4. Inspiration lasts longer than expiration 5. Inspiration and expiration equal in duration Answer: 1, 2, 3, 5 Explanation: 1. Bronchovesicular breath sounds are of medium pitch. 2. Bronchovesicular breath sounds are heard between the scapula. 3. Bronchovesicular breath sounds are heard on each side of the sternum. 4. Vesicular breath sounds have longer inspirations than expirations. 5. Bronchovesicular breath sounds have equal inspiration and expiration. Page Ref: 1226 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

35 ..

36) During an assessment, the nurse learns that a patient has an alteration in the sense of smell. What should the nurse consider as causes of this alteration? Select all that apply. 1. Rhinoplasty 2. Zinc deficiency 3. Deviated septum 4. Olfactory nerve damage 5. Chronic inflammation of the nose Answer: 2, 4, 5 Explanation: 1. Rhinoplasty is not identified as altering the sense of smell. 2. Zinc deficiency may cause a loss of the sense of smell. 3. A deviated septum is not identified as altering the sense of smell. 4. Changes in the ability to smell may be the result of damage to the olfactory nerve. 5. Changes in the ability to smell may be the result of chronic inflammation of the nose. Page Ref: 1224 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

36 ..

37) A patient who never smoked wonders why the cancer occurred. What is the nurse's best response? 1. "It could have been caused by a high-sodium diet." 2. "Are you sure you never smoked?" 3. "There may have been a genetic predisposition." 4. "No one will ever know." Answer: 3 Explanation: 1. No association has been made between lung cancer and a high-sodium diet. 2. Suggesting that the patient was not being honest is inappropriate. 3. A familial history of lung cancer increases the risk of developing lung cancer, and small-cell lung cancer has a definite genetic component. In addition, researchers have found that patients with lung cancer who never smoked are more likely than smokers to have one of two genetic mutations linked to the disease. 4. The causes for lung cancer have been studied. Page Ref: 1223 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 34.2 Outline the components of the assessment of the respiratory system including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the respiratory system collected during assessment.

37 ..

38) The nurse is preparing a teaching tool on respiratory health. Which information should the nurse include in this tool? Select all that apply. 1. Stop smoking. 2. Restrict fluid intake. 3. Use good hand hygiene. 4. Use good cough technique. 5. Get recommended vaccinations. Answer: 1, 3, 4, 5 Explanation: 1. Smoking damages the lungs while increasing the risk for lung cancer and COPD. 2. Restricting fluids will thicken respiratory secretions and encourage infections. 3. Frequent handwashing with good technique (warm water, soap, friction for at least 15 seconds, rinse well) reduces most of the common shared bacteria. 4. Covering the mouth and nose with a tissue will help to stop the spread of germs. Coughing into a bent elbow is an option when no tissues are available 5. Yearly influenza vaccinations are health-promoting behaviors, especially in those who are exposed to children, older adults, or persons who are sick. Page Ref: 1230 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 34.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

38 ..

39) During a home visit, the nurse observes that several family members are experiencing a respiratory infection. Which should the nurse encourage to improve the home environment? Select all that apply. 1. Remove house plants. 2. Limit the use of aerosols. 3. Have radon level checked. 4. Use a wood-burning stove. 5. Remove dust and pet dander. Answer: 2, 3, 5 Explanation: 1. House plants do not contribute to pollution in the home. 2. Indoor pollution caused by aerosols contributes to lung damage. 3. Radon is a radioactive gas that contributes to respiratory problems. 4. Wood-burning stoves contribute to indoor pollution and can cause lung damage. 5. Removing dust and pet dander reduces environmental allergens. Page Ref: 1230 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 34.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the respiratory system collected during assessment and health promotion activities to support the health of this body system.

39 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 35 Nursing Care of Patients with Upper Respiratory Disorders 1) A patient tells the nurse he has a "cold" every spring that lasts a few weeks. Which health problem should the nurse suspect the patient is experiencing? 1. Acute viral rhinitis 2. Allergic rhinitis 3. Vasomotor rhinitis 4. Atrophic rhinitis Answer: 2 Explanation: 1. Acute viral rhinitis is the common cold. 2. Allergic rhinitis, or hay fever, results from a sensitivity reaction to allergens such as plant pollens. It tends to occur seasonally. 3. The etiology of vasomotor rhinitis is unknown. Although its manifestations are similar to those of allergic rhinitis, it is not linked to allergens. 4. Atrophic rhinitis is characterized by changes in the mucous membrane of the nasal cavities. Page Ref: 1234 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

1 ..

2) A patient reports having a congested nose that is worse after using a nasal spray. Which manifestation is this patient describing? 1. Incorrect use of the nasal spray 2. Acute sinus infection that needs to be treated with antibiotics 3. Adverse effect of the nasal spray 4. Rebound nasal congestion Answer: 4 Explanation: 1. The nasal spray is being used correctly. 2. No other signs indicate that the patient has a bacterial sinus infection. 3. The worsening nasal congestion is not considered an adverse effect. 4. Chronic use of nasal sprays may lead to rhinitis medicamentosa, a rebound phenomenon of drug-induced nasal irritation and inflammation. Page Ref: 1235 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

2 ..

3) A middle-aged patient is seen in the clinic for a continuing cough after recovering from the flu "a few weeks ago." What should the nurse suspect is occurring with this patient? 1. Viral pneumonia 2. Sinus infection 3. Otitis media 4. Tracheobronchitis Answer: 4 Explanation: 1. No other signs of viral pneumonia are described in the scenario. 2. No other signs of sinus infection are described in the scenario. 3. Cough is not common with otitis media. 4. The respiratory epithelial necrosis caused by influenza increases the risk for secondary bacterial infections. Tracheobronchitis, which is inflammation of the trachea and bronchi, may develop. While tracheobronchitis is not a serious health risk, its manifestations may persist for up to 3 weeks. Page Ref: 1240 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

3 ..

4) A patient who was diagnosed with the flu is demonstrating rapid, shallow respirations. For which health problem should the nurse suspect the patient is at risk for developing? 1. Atelectasis 2. Pneumonia 3. Dehydration 4. Increased tidal volume Answer: 1 Explanation: 1. Muscle aches, malaise, and elevated temperature may increase the respiratory rate and alter the depth of respirations, reducing effective alveolar ventilation. Shallow respirations also increase the risk of atelectasis, lack of ventilation in an area of lung. 2. A patient would be at risk for pneumonia if he or she had reduced mobility. 3. Rapid respirations may contribute to water loss that occurs naturally with the process of breathing, but it would not be large enough to induce dehydration. 4. Shallow respirations decrease tidal volume in an area of lung. Page Ref: 1241 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper respiratory disorders.

4 ..

5) A patient reports needing to see a dentist because of upper teeth pain. Which action should the nurse take? 1. Suggest the patient see the dentist immediately. 2. Assess the patient for a sinus infection. 3. Schedule an appointment with the healthcare provider. 4. Inform the patient there is nothing wrong with the teeth. Answer: 2 Explanation: 1. The tooth pain is not necessarily a dental problem. 2. Manifestations of sinusitis include pain and tenderness across the infected sinuses, plus headache, fever, and malaise. When the maxillary sinuses are involved, pain and pressure are felt over the cheek. The pain may be referred to the upper teeth. 3. The patient may or may not need to see the healthcare provider. An assessment should be completed first. 4. Until an assessment is performed and a diagnosis is made or ruled out, it would be incorrect to tell the patient that nothing is wrong. Page Ref: 1243 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

5 ..

6) During an assessment, the nurse learns that the only thing that helps a patient with a daily morning headache is "using a vaporizer with eucalyptus" before breakfast. Which health problem should the nurse suspect the patient is experiencing? 1. Acute rhinitis 2. Allergic rhinitis 3. Symptoms of sinusitis 4. After-effects from the flu Answer: 3 Explanation: 1. Rhinitis is inflammation of the nasal passages. A eucalyptus cough drop would not relieve inflammation. 2. Rhinitis is inflammation of the nasal passages. A eucalyptus cough drop would not relieve inflammation. 3. Complementary therapies are often used to alleviate the symptoms of sinusitis. Aromatherapy using herbs such as eucalyptus may be used. 4. The scenario does not mention any history of the flu. Page Ref: 1245 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

6 ..

7) The nurse suspects that a patient has tonsillitis. What did the nurse assess to make this clinical decision? Select all that apply. 1. Hoarse voice 2. Thirst 3. Nucal rigidity 4. Pain around the ears 5. Low-grade fever Answer: 1, 4, 5 Explanation: 1. Manifestations of tonsillitis include a hoarse voice. 2. Thirst is not a manifestation of tonsillitis. 3. Nuchal rigidity is not a manifestation of tonsillitis. 4. Otalgia (pain referred to the ear) is a manifestation of tonsillitis. 5. Fever is a manifestation of tonsillitis. Page Ref: 1246 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

7 ..

8) A middle-aged adult patient who is diagnosed with pertussis is complaining of right-sided thoracic pain. For which health problem should the nurse assess this patient? Select all that apply. 1. Pleural effusion 2. Pneumothorax 3. Pulmonary emboli 4. Rib fractures 5. Pleurisy Answer: 2, 4 Explanation: 1. Pleural effusion is a collection of fluid in the lungs and is not a result of pertussis. 2. Complications of pertussis in adults, including pneumothorax, may result from increased intrathoracic pressure during prolonged coughing spells. 3. Pulmonary emboli are clots in the lung and are not a result of pertussis. 4. Complications of pertussis in adults, including rib fractures, may result from increased intrathoracic pressure during prolonged coughing spells. 5. Pleurisy is pain related to inflammation of the pleurae and is not associated with pertussis. Page Ref: 1252 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

8 ..

9) A patient is receiving anterior nasal packing for a nosebleed. What should be included in the instructions for this patient? 1. Remove the packing in the morning. 2. The packing will stay in place for at least 5 days. 3. The packing will be in place for at least 24 hours and up to 3 days. 4. The packing will be needed for at least 1 week. Answer: 3 Explanation: 1. Anterior nasal packs are usually left in place for 24 to 72 hours. 2. Anterior nasal packs are usually left in place for 24 to 72 hours. 3. Anterior nasal packs are usually left in place for 24 to 72 hours. If epistaxis is caused by a bleeding disorder, the packing may be left in place for 4 to 5 days while the disorder is treated. 4. Anterior nasal packs are usually left in place for 24 to 72 hours. Page Ref: 1255 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

9 ..

10) While engaging in a high school sports activity, an adolescent sustains an injury to the nose. Which assessment finding indicates that the patient has a nasal fracture? Select all that apply. 1. Shortness of breath 2. Diaphoresis 3. Drop in blood pressure 4. Periorbital ecchymosis 5. Nasal bridge instability Answer: 4, 5 Explanation: 1. Shortness of breath is not a manifestation of nasal fracture. 2. Diaphoresis is not a manifestation of nasal fracture. 3. A drop in blood pressure is not a manifestation of nasal fracture. 4. Manifestations of a fractured nose include periorbital ecchymosis. 5. Manifestations of a fractured nose include nasal bridge instability. Page Ref: 1257 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

10 ..

11) A patient with multiple facial and nasal injuries needs a nasogastric tube placed. Which method should the nurse use to place this tube? 1. Through the mouth 2. Through the unobstructed nare 3. Through the obstructed nare 4. After the edema in the nares subsides Answer: 2 Explanation: 1. A tube placed through the mouth would be an orogastric tube. 2. The nasogastric tube is inserted through the unobstructed nare to avoid mucosal trauma. 3. A tube could not be placed through an obstructed nare. 4. The nasal edema may persist for a long period, so waiting would not be appropriate. Page Ref: 1258 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

11 ..

12) While eating a meal in the hospital, a patient exhibits difficulty breathing and signs of choking. What should the nurse realize the patient is experiencing? 1. Laryngeal obstruction 2. Pulmonary emboli 3. Epiglottitis 4. Acute myocardial infarction Answer: 1 Explanation: 1. The most common cause of laryngeal obstruction in adults is ingested meat that lodges in the airway. 2. Pulmonary emboli would not likely be the cause of choking for this patient. 3. Epiglottitis is an infection and is not described in this case. 4. Acute myocardial infarction would not be an obvious diagnosis in this case. Page Ref: 1259 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

12 ..

13) The nurse observes a patient's respirations during sleep and notes the absence of respirations that lasts from 15 to 45 seconds. What should the nurse consider this patient is experiencing? 1. Laryngeal spasm 2. Sleep apnea 3. Respiratory acidosis 4. Renal failure Answer: 2 Explanation: 1. No symptoms of laryngeal spasm are noted. 2. Manifestations of obstructive sleep apnea include periods of apnea that last 15 to 120 seconds. 3. Respiratory acidosis would be diagnosed from arterial blood gases. 4. No symptoms of renal failure are described. Page Ref: 1263 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

13 ..

14) A patient who is scheduled for a partial laryngectomy asks if he will still be able to talk after the surgery. Which response would be appropriate for the nurse to make? Select all that apply. 1. "No." 2. "You will have to ask your physician." 3. "Yes, but it might sound a little different." 4. "You will, but with an electronic device." 5. "Normal speaking, breathing, and swallowing will return as you recover." Answer: 3, 5 Explanation: 1. In a partial laryngectomy, 50% or more of the larynx is removed. The voice generally is well preserved. 2. With knowledge of a partial laryngectomy, the nurse is able to answer the question. 3. In a partial laryngectomy, 50% or more of the larynx is removed. The voice generally is well preserved, although it may be changed by the surgery. 4. The use of an electronic device is generally not necessary following a partial laryngectomy. 5. The patient can expect normal speaking, breathing, and swallowing to return upon recovery from surgery. Page Ref: 1269 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.3 Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

14 ..

15) While recovering at home from a total laryngectomy, a patient notices an increase in left shoulder weakness. With what should the nurse realize this symptom is consistent? 1. Normal recovery 2. Damage to the spinal accessory nerve 3. Side effect of neck radiation therapy 4. Medication complication Answer: 2 Explanation: 1. Left shoulder weakness in not a normal finding in a post-laryngectomy patient. 2. Left shoulder drop may be caused by damage to the spinal accessory nerve. This finding should be reported to the physician. 3. There is no mention of radiation treatments. 4. Medications are not mentioned in the history. Page Ref: 1270 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.3 Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

15 ..

16) A patient with laryngeal cancer is found to have carcinoma in situ. For which stage of cancer should the nurse plan care for this patient? 1. Stage 0 2. Stage I 3. Stage II 4. Stage III Answer: 1 Explanation: 1. A stage 0 laryngeal tumor is carcinoma in situ with no lymph node involvement. 2. Carcinoma in situ is not stage I. 3. Carcinoma in situ is not stage II. 4. Carcinoma in situ is not stage III. Page Ref: 1269 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35.3 Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper respiratory disorders.

16 ..

17) A patient with nasal trauma has clear, watery fluid dripping from the nose. After testing, the nurse learns this fluid contains glucose. What should this finding indicate to the nurse? 1. There is a fracture of the ethmoid or sphenoid sinus. 2. The patient needs to be suctioned. 3. Cerebrospinal fluid is present. 4. The patient has coryza. Answer: 3 Explanation: 1. Clear nasal drainage is not an indication of a fracture. 2. Patients with nasal fracture should not be suctioned, as this may introduce microorganisms and cause additional tissue trauma. 3. Clear, watery fluid draining from the nose or ear of a patient who has suffered nasal trauma should be tested for the presence of glucose. Cerebrospinal fluid will test positive on a glucose test strip, indicating damage to the dura and increasing the patient's risk of meningitis and ascending infection. 4. Coryza is the term for clear, watery nasal discharge that often presents with the common cold. Page Ref: 1257 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper respiratory disorders.

17 ..

18) During a health history, the nurse learns that a patient experiences several head colds each year. What teaching should the nurse consider providing to this patient? Select all that apply. 1. Limit physical stress. 2. Avoid getting chilled. 3. Stay away from crowds. 4. Stay indoors when it rains. 5. Frequently wash the hands. Answer: 1, 3, 5 Explanation: 1. The patient should be instructed that URIs are more likely to occur during periods of physical stress. 2. The patient should be instructed that becoming chilled does not cause colds. 3. Patients can limit their incidence of acute viral URI by avoiding exposure to crowds. 4. The patient should be instructed that going out in the rain does not cause colds. 5. Patients can limit their incidence of acute viral URI by frequent hand washing. Page Ref: 1237 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

18 ..

19) The nurse is caring for patients who have been exposed to the influenza virus. For which patient should the nurse question the use of the antiviral drug zanamivir (Relenza)? Select all that apply. 1. Patient with arthritis 2. Patient with heart failure 3. Patient diagnosed with COPD 4. Patient being treated for asthma 5. Patient with type 2 diabetes mellitus Answer: 3, 4 Explanation: 1. The antiviral drug zanamivir (Relenza) may be used to reduce the duration and severity of flu symptoms. It is not contraindicated in patients with arthritis. 2. The antiviral drug zanamivir (Relenza) may be used to reduce the duration and severity of flu symptoms. It is not contraindicated in patients with heart failure. 3. The antiviral drug zanamivir (Relenza) may be used to reduce the duration and severity of flu symptoms. Zanamivir can precipitate bronchospasm in patients with a history of chronic obstructive pulmonary disease (COPD) and is not recommended for use in these patients. 4. The antiviral drug zanamivir (Relenza) may be used to reduce the duration and severity of flu symptoms. Zanamivir can precipitate bronchospasm in patients with a history of asthma and is not recommended for use in these patients. 5. The antiviral drug zanamivir (Relenza) may be used to reduce the duration and severity of flu symptoms. It is not contraindicated in patients with type 2 diabetes mellitus. Page Ref: 1241 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper respiratory disorders.

19 ..

20) A patient has an ongoing sinus infection. In addition to antibiotics, which treatment should the nurse expect to be prescribed for this patient? Select all that apply. 1. Topical steroids 2. Saline nose drops 3. Saltwater gargles 4. Oral decongestants 5. Warm steam inhalation Answer: 1, 2, 4, 5 Explanation: 1. Topical steroids are prescribed to reduce mucosal edema and promote sinus drainage. 2. Saline nose drops promote sinus drainage. 3. Saltwater gargles will not help in the treatment of a sinus infection. 4. Oral decongestants are prescribed to reduce mucosal edema and promote sinus drainage. 5. Inhalation of warm steam promotes sinus drainage. Page Ref: 1244 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

20 ..

21) The nurse provides discharge instructions to a patient recovering from endoscopic sinus surgery. Which patient statement indicates that teaching has been effective? Select all that apply. 1. "I need to sneeze with my mouth open." 2. "I should avoid heavy lifting for a week." 3. "I am to avoid blowing my nose for a week." 4. "I am to irrigate the sinuses with normal saline." 5. "The nasal packing will be removed in 2 days." Answer: 1, 2, 3, 4 Explanation: 1. Patients who have endoscopic sinus surgery should be instructed to sneeze with the mouth open. 2. Patients who have endoscopic sinus surgery should be instructed to avoid lifting for 1 week. 3. Patients who have endoscopic sinus surgery should be instructed to avoid blowing the nose for 1 week. 4. Patients who have endoscopic sinus surgery should be instructed to irrigate the sinuses with normal saline. 5. Patients who have endoscopic sinus surgery usually do not require nasal packing postoperatively. Page Ref: 1244 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

21 ..

22) A patient with a penicillin allergy is diagnosed with scarlet fever. Which medication should the nurse anticipate being prescribed for this patient? Select all that apply. 1. Amoxicillin 2. Cefuroxime 3. Erythromycin 4. Dexamethasone 5. Pseudoephedrine Answer: 1, 2, 3 Explanation: 1. Scarlet fever is caused by the streptococcus bacteria, and penicillin is the medication of choice. In the event of a penicillin allergy, amoxicillin may be used. 2. Scarlet fever is caused by the streptococcus bacteria, and penicillin is the medication of choice. In the event of a penicillin allergy, cefuroxime may be used. 3. Scarlet fever is caused by the streptococcus bacteria, and penicillin is the medication of choice. In the event of a penicillin allergy, erythromycin may be used. 4. Dexamethasone is a steroid and is not indicated in the treatment of a streptococcus infection. 5. Pseudoephedrine is an antihistamine and is not indicated in the treatment of a streptococcus infection. Page Ref: 1247 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

22 ..

23) The community health nurse learns that an adult community member has been diagnosed with diphtheria. What should the nurse do to prevent the spread of this infection? Select all that apply. 1. Provide the Tdap vaccine as prescribed. 2. Instruct the patient to ingest milk and dairy products. 3. Obtain throat cultures from the patient's close contacts. 4. Ensure the patient's diagnosis has been reported to the local health department. 5. Counsel the patient's family members to take antibiotics for 3 days as prescribed. Answer: 1, 3, 4, 5 Explanation: 1. Preventing further cases of diphtheria is a nursing responsibility. All contacts should receive the tetanus, diphtheria, and pertussis (Tdap) vaccine, which is given only once. 2. Milk and dairy products thicken respiratory secretions, which would not be ideal for the patient with diphtheria because the respiratory tract is affected with a thick pseudomembranous material. 3. Preventing further cases of diphtheria is a nursing responsibility. Throat cultures are obtained from all close contacts. 4. Diphtheria is a reportable disease. The local health department and the Centers for Disease Control and Prevention should be informed about all suspected and confirmed cases. 5. Preventing further cases of diphtheria is a nursing responsibility. Asymptomatic disease carriers are confined to home until at least 3 days of antibiotic therapy have been completed. Page Ref: 1251 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

23 ..

24) A patient seeks medical attention for a nosebleed. Which action should the nurse take to help this patient? Select all that apply. 1. Pinch the nose toward the septum. 2. Apply ice to the nose and forehead. 3. Place the patient in a seated position. 4. Insert rolled gauze pads into each nare. 5. Assist the patient to lean back when seated. Answer: 1, 2, 3 Explanation: 1. Anterior bleeding can usually be managed with simple first-aid measures, such as applying pressure or pinching the nose toward the septum for 5 to 10 minutes. 2. Anterior bleeding can usually be managed with simple first-aid measures, such as applying ice packs to the nose and forehead to cause vasoconstriction. 3. Anterior bleeding can usually be managed with simple first-aid measures, such as having the patient in a sitting position to decrease blood flow to the head and reduce venous pressure. 4. Anterior bleeding can usually be managed with simple first-aid measures. If applying pressure does not control the bleeding, nasal packing may be necessary. 5. Anterior bleeding can usually be managed with simple first-aid measures. Leaning forward rather than back reduces drainage of blood backward into the nasopharynx and decreases swallowing of blood. Page Ref: 1254 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

24 ..

25) The nurse is preparing discharge instructions for a patient recovering from a rhinoplasty. What should the nurse include in these instructions? Select all that apply. 1. Apply ice to the nose. 2. Restrict oral fluid intake. 3. Avoid vigorous coughing. 4. Elevate the head of the bed on blocks. 5. Expect eye bruising for several weeks. Answer: 1, 3, 4 Explanation: 1. Following rhinoplasty, the patient should be instructed to apply ice packs to the nose to relieve discomfort and reduce swelling. 2. Following rhinoplasty, the patient should be instructed to increase fluid intake to reduce oral dryness due to mouth breathing. 3. Following rhinoplasty, the patient should be instructed to avoid vigorous coughing, which may cause bleeding. 4. Following rhinoplasty, the patient should be instructed to elevate the head of the bed on blocks to reduce local edema. 5. Following rhinoplasty, the patient should be instructed to expect bruising around the eyes and nose to last for several days, not weeks. Page Ref: 1259 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

25 ..

26) The public health nurse is preparing an education program on preventing laryngeal trauma and obstruction for community members. What should the nurse include in this program? Select all that apply. 1. How to perform the Heimlich maneuver. 2. Abstain from eating when ingesting alcohol. 3. Carry a list of medications in a wallet at all times. 4. Wear a medical alert bracelet if allergic to stinging insects. 5. People who wear dentures should take small bites when eating. Answer: 1, 2, 4, 5 Explanation: 1. Health promotion and teaching for home care focus on preventing laryngeal obstruction and early intervention techniques. The nurse should promote training of the general public in CPR and the Heimlich maneuver. The more people who are adequately trained in emergency procedures, the more likely emergency procedures will be initiated in a timely manner. 2. Health promotion and teaching for home care focus on preventing laryngeal obstruction and early intervention techniques. Everyone should be aware of the risk factors for adult aspiration and the relationship between excess alcohol intake and food aspiration. 3. Health promotion and teaching for home care focus on preventing laryngeal obstruction and early intervention techniques. There is no need to carry a list of medications in the wallet at all times. 4. Health promotion and teaching for home care focus on preventing laryngeal obstruction and early intervention techniques. Patients with a known risk for anaphylaxis, such as people with a previous anaphylactic response and those allergic to bee venom, should wear a medical alert tag to allow early intervention to prevent severe laryngeal edema and spasm. 5. Health promotion and teaching for home care focus on preventing laryngeal obstruction and early intervention techniques. Everyone should be aware of the risk factors for adult aspiration. Patients who wear dentures should take small bites, chewing each bite carefully before swallowing. Page Ref: 1263 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

26 ..

27) During a health history, the nurse suspects that a patient may be experiencing sleep apnea. What finding led the nurse to make this clinical decision? Select all that apply. 1. The patient is yawning. 2. Blood pressure is 188/92 mmHg. 3. The patient reports having a headache every morning. 4. The patient reports a change in appetite and a 10 lb weight loss in 2 months. 5. The patient says family members complain about snoring. Answer: 1, 2, 3, 5 Explanation: 1. Daytime sleepiness is a manifestation of sleep apnea. 2. Hypertension is a manifestation of sleep apnea. 3. A morning headache is a manifestation of sleep apnea. 4. Changes in appetite and weight loss are not manifestations of sleep apnea. 5. Loud cyclic snoring is a manifestation of sleep apnea. Page Ref: 1263 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.2 Describe the pathophysiology and manifestations of disorders of upper respiratory trauma or obstruction and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with upper respiratory disorders.

27 ..

28) A patient recovering from a total laryngectomy and permanent tracheostomy is being discharged. What observation indicates that discharge teaching has been effective? Select all that apply. 1. The patient supports the head when moving in bed. 2. The patient drinks cool fluids throughout the day. 3. The patient is eager to go to the pool to go swimming. 4. The patient places a gauze sponge around the gastrostomy tube. 5. The patient covers the tracheostomy with a light gauze sponge. Answer: 1, 2, 5 Explanation: 1. Supporting the head when moving in bed reduces the strain on tissues in the operative area. 2. Adequate fluid intake keeps secretions liquid and mucous membranes moist. 3. The patient with a permanent tracheostomy cannot participate in water sports. 4. Because the trachea and the esophagus are permanently separated by this surgery, there is no risk of aspiration during swallowing. A gastrostomy tube is not needed. 5. Protecting the stoma from particulate matter in the air with gauze squares prevents foreign material from entering the lungs. Page Ref: 1271 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 35.3 Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

28 ..

29) A patient avoids people with obvious colds and does not understand why colds continue to develop throughout the winter. What should the nurse respond to this patient? Select all that apply. 1. Vaccinations would prevent the development of colds. 2. There are more than 200 strains of viruses that cause colds. 3. People can be infected with a virus before symptoms occur. 4. Drinking more fluids will prevent the development of colds. 5. Viruses can be spread through direct contact from contaminated objects. Answer: 2, 3, 5 Explanation: 1. No specific antiviral therapy has proven effective in preventing URIs or shortening their duration. 2. More than 200 strains of virus cause upper respiratory infections. 3. Infected patients are highly contagious, shedding virus for a few days prior to the appearance of symptoms. 4. Drinking more fluids does not prevent the development of colds. 5. Viruses causing acute URIs spread by direct contact. Page Ref: 1234 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

29 ..

30) A patient is prescribed fexofenadine (Allegra) for allergic rhinitis. For which reason should the nurse question providing the medication to this patient? Select all that apply. 1. History of asthma 2. Treatment for glaucoma 3. Type 2 diabetes mellitus controlled by diet 4. Medication for benign prostatic hypertrophy 5. Over-the-counter pain medication for arthritis Answer: 1, 2, 4 Explanation: 1. Before administering this medication, the nurse should assess for possible contraindications, including acute asthma that may be aggravated by the drying of secretions. 2. Before administering this medication, the nurse should assess for possible contraindications, including glaucoma. 3. This medication is not contraindicated in patients with type 2 diabetes mellitus. 4. Before administering this medication, the nurse should assess for possible contraindications, including prostatic hypertrophy. 5. This medication is not contraindicated in patients with arthritis. Page Ref: 1235 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with upper respiratory disorders.

30 ..

31) An older patient with influenza is encouraged to drink plenty of fluids and get adequate rest to prevent the development of complications. What physiological change is the nurse most concerned about in this patient? Select all that apply. 1. Reduced thirst reflex 2. Altered hypothalamic response 3. Increased residual lung volume 4. Reduced effectiveness of cough 5. Muted chemoreceptors in the aortic arch Answer: 3, 4 Explanation: 1. Older patients may experience a change in thirst; however, this is not a reason the nurse is concerned about the development of complications from influenza in this patient. 2. There is no evidence that the hypothalamic response is altered in older patients. 3. Influenza is clearly linked to an increased risk for pneumonia, particularly in older adults. Changes in respiratory function associated with aging include increased residual lung volume. 4. Influenza is clearly linked to an increased risk for pneumonia, particularly in older adults. Changes in respiratory function associated with aging include reduced effectiveness of cough. 5. There is no evidence that chemoreceptors in the aortic arch are muted in older patients. Page Ref: 1240 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

31 ..

32) A hospitalized patient is diagnosed with influenza. What action should the nurse take to help this patient? Select all that apply. 1. Assign the patient to a private room. 2. Implement droplet precautions. 3. Wear a mask when caring for the patient. 4. Measure the patient for a HEPA filter face mask. 5. Apply a mask to the patient when transporting the patient out of the room. Answer: 1, 2, 3, 5 Explanation: 1. Patients with confirmed influenza should be assigned to a private room. 2. Droplet precautions should be implemented for patients with confirmed influenza. 3. A mask should be worn when caring for a patient with confirmed influenza. 4. A mask with a HEPA filter is used by healthcare providers when caring for patients with tuberculosis. 5. A patient with confirmed influenza should wear a mask when being transported out of the room. Page Ref: 1242 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

32 ..

33) A patient with chronic sinus infections is scheduled for the Caldwell-Luc procedure. What should the nurse include when teaching the patient about this procedure? Select all that apply. 1. Dentures should be inserted immediately after the surgery. 2. Avoid the Valsalva maneuver for 2 weeks after the surgery. 3. Packing will be present for 24 to 48 hours after the procedure. 4. A liquid diet will be permitted for the first day after the surgery. 5. The upper lip and teeth may be numb for several months after the surgery. Answer: 2, 3, 4, 5 Explanation: 1. The patient is instructed to avoid wearing dentures for about 2 weeks after the packing has been removed to prevent bleeding. 2. The patient should be instructed to avoid the Valsalva maneuver (no blowing the nose, coughing, or straining at stool) for about 2 weeks after the packing has been removed to prevent bleeding. 3. The Caldwell-Luc procedure may be necessary if endoscopic sinus surgery is unsuccessful. It is performed under local or general anesthesia. An incision is made under the upper lip into the maxillary sinus, and diseased mucous membrane and periosteum are removed. An opening between the maxillary sinus and lateral nasal wall, a "nasal antral window," is created to increase aeration of the sinus and promote drainage into the nasal cavity. The area is packed with gauze for 24 to 48 hours postoperatively. 4. Only liquids are given for the first 24 hours, followed by a soft diet. 5. The upper lip and teeth may be numb for several months after the procedure because of nerve trauma. Page Ref: 1244 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

33 ..

34) The nurse is planning care for a patient with viral laryngitis. What should the nurse include when teaching the patient about care for this condition? Select all that apply. 1. Avoid all tobacco. 2. Do not use the voice. 3. Avoid ingesting alcohol. 4. Take all antibiotics as prescribed. 5. Spray the throat with antiseptic solution as prescribed. Answer: 1, 2, 3, 5 Explanation: 1. There is no specific treatment for viral laryngitis. Abstinence from tobacco is advised. 2. There is no specific treatment for viral laryngitis. Voice rest is advised. 3. There is no specific treatment for viral laryngitis. Abstinence from alcohol is advised. 4. There is no specific treatment for viral laryngitis. Antibiotics are not prescribed. 5. There is no specific treatment for viral laryngitis. Treatment may include spraying the throat with antiseptic solutions. Page Ref: 1249 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

34 ..

35) A patient's nasopharyngeal culture results are positive for B. pertussis. What action should the nurse take for this patient? Select all that apply. 1. Restrict fluids. 2. Monitor intake and output. 3. Place in respiratory isolation. 4. Administer erythromycin as prescribed. 5. Report the test results to the local health department. Answer: 3, 4, 5 Explanation: 1. Fluids do not need to be restricted for pertussis. 2. Intake and output do not need to be monitored for pertussis. 3. Respiratory isolation is instituted for 5 days after antibiotic therapy is started. 4. Erythromycin is the antibiotic of choice to eradicate B. pertussis infection. 5. All probable and confirmed cases of pertussis must be reported to the local health department and the Centers for Disease Control and Prevention. Page Ref: 1253-1254 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Content and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 35.1 Describe the pathophysiology and manifestations of infectious and inflammatory upper respiratory disorders and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with upper respiratory disorders.

35 ..

36) During an assessment, the nurse is concerned that a patient is at risk for developing laryngeal cancer. What did the nurse assess to make this clinical decision? Select all that apply. 1. The patient works in a steel mill. 2. The patient is a 68-year-old African American male. 3. The patient smokes two packs of cigarettes a day. 4. The patient eats a salad every night with dinner. 5. The patient drinks beer and whiskey every night. Answer: 1, 2, 3, 5 Explanation: 1. Risk factors for laryngeal cancer include exposure to asbestos and other occupational pollutants. 2. Laryngeal cancer is more common in African Americans and usually develops between the ages of 50 and 70. Men are affected more than four times as often as women. 3. Tobacco use is the major risk factor for laryngeal cancer. The risk of developing laryngeal cancer is significantly greater in smokers than in nonsmokers. 4. Eating salad does not predispose a person to developing laryngeal cancer. 5. Alcohol consumption is a significant cofactor in increasing the risk. When combined with smoking, the risk increases synergistically and significantly, perhaps as much as 100 times. Page Ref: 1268 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 35.3 Describe the pathophysiology and manifestations of upper respiratory tumors and outline the interprofessional care and nursing care of patients with upper respiratory tumors. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with upper respiratory disorders.

36 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 36 Nursing Care of Patients with Ventilation Disorders 1) The nurse is caring for a patient with bacterial pneumonia. Which classification of medications should the nurse expect to be prescribed for this patient? Select all that apply. 1. Antibiotics 2. Steroids 3. Bronchodilators 4. Antiemetics 5. Antihistamines Answer: 1, 3 Explanation: 1. Antibiotics are indicated in a bacterial infection. 2. Steroids are recommended in inflammatory, not bacterial, disorders. 3. Bronchodilators are commonly prescribed to decrease bronchospasm and increase ventilation. 4. Antiemetics are not typically indicated for bacterial pneumonia. 5. Antihistamines are more commonly associated with allergy treatment. Page Ref: 1285 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.

1 ..

2) A clinic is being conducted to provide influenza (flu) and pneumonia vaccines for adults. Prior to administration of a flu vaccine, for what should the nurse assess the patients? 1. Current antibiotic therapy 2. Pulse oximeter saturation level 3. Allergy to mercury 4. Allergy to eggs Answer: 4 Explanation: 1. Current antibiotic therapy would not impact the vaccine. 2. Pulse oximeter reading is not taken before the vaccine is administered. 3. Allergy to mercury is not routinely assessed. 4. Assessing for an allergy to eggs or previous influenza vaccines is necessary prior to administration. A hypersensitivity to egg protein may be invoked after administration of the influenza vaccine due to additives in the vaccine. Page Ref: 1285 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

2 ..

3) A patient with pneumonia is having difficulty maintaining a clear airway. Which action should the nurse take to ensure this patient is adequately ventilated? Select all that apply. 1. Assess skin color at least every four hours. 2. Assess breath sounds at least every four hours. 3. Assess oxygen saturation level at least every four hours. 4. Assess vital signs daily. 5. Assess respiratory rates every shift. Answer: 1, 2, 3 Explanation: 1. By assessing the skin at least every four hours, the nurse will be able to detect subtle changes that could indicate impending changes with the patient. 2. Respiratory rates must be assessed on a frequency level similar to the breath sounds assessment, if not more often. 3. By assessing the oxygen saturation levels at least every four hours, the nurse will be able to detect subtle changes that could indicate impending changes with the patient. 4. Vital signs should be assessed more frequently than every day. 5. Respiratory rates must be assessed on a frequency level similar to the breath sounds assessment, if not more often. Page Ref: 1288 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

3 ..

4) The nurse is caring for a patient diagnosed with severe acute respiratory syndrome (SARS). What should the nurse expect to assess in this patient? Select all that apply. 1. Nasal flaring 2. Restlessness 3. Anxiety 4. Decreased level of consciousness 5. Sputum production Answer: 1, 2, 3, 4 Explanation: 1. Nasal flaring is an early indicator of respiratory failure or inability to maintain ventilatory effort. 2. Restlessness is an early indicator of respiratory failure or inability to maintain ventilatory effort. 3. Anxiety is an early indicator of respiratory failure or inability to maintain ventilatory effort. 4. Decreased level of consciousness is an early indicator of respiratory failure or inability to maintain ventilatory effort. 5. Sputum production is not a common assessment finding in SARS. Page Ref: 1290 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

4 ..

5) A patient is prescribed isoniazid (INH) and rifampin for treatment of tuberculosis. Which adverse effect should the nurse instruct the patient to report to the healthcare provider? Select all that apply. 1. Fever 2. Yellow tint to the skin 3. Episodic pain in the upper-left quadrant 4. Diarrhea 5. Change in stool color Answer: 2, 5 Explanation: 1. A fever would not indicate hepatitis. 2. INH and rifampin can cause hepatitis. Jaundice could indicate hepatitis. 3. The pain from hepatitis is on the upper-right quadrant, not the left. 4. Diarrhea would not indicate hepatitis. 5. A change in stool color could be an indication of hepatitis. Page Ref: 1299-1300 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

5 ..

6) A patient diagnosed with tuberculosis is prescribed ethambutol (EMB). Prior to initiating this medication, what should the nurse instruct the patient? 1. Avoid this medication if allergic to eggs. 2. Have a baseline visual examination. 3. Have an influenza (flu) vaccination. 4. Have a baseline ECG (electrocardiogram). Answer: 2 Explanation: 1. Assessment of an allergy to eggs is not warranted prior to the implementation of this medication. 2. Before starting on ethambutol (EMB), a baseline visual examination is indicated. Eye examinations also may be scheduled during the course of treatment. This medication can cause optic neuritis. 3. Administration of a flu vaccine is not warranted prior to the implementation of this medication. 4. An ECG is not warranted prior to the implementation of this medication. Page Ref: 1300 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

6 ..

7) A patient diagnosed with active tuberculosis is in a negative pressure room for respiratory airborne isolation. How long should the nurse maintain the patient in this type of isolation? 1. Until sputum specimens for acid-fast bacilli are negative 2. Until the Mantoux test (PPD) converts from positive to negative 3. Until the patient has orders for discharge 4. Until the chest x-ray is normal Answer: 1 Explanation: 1. The patient should remain in isolation until sputum cultures have tested negative. Until that time and in spite of treatment, there is no certainty that the patient is not infectious. 2. A positive PPD indicates that an individual has been exposed to tuberculosis and has developed antibodies, so the PPD will not convert back to negative. 3. The patient should not be discharged without evidence that he or she is no longer infectious. 4. The chest x-ray validates the amount of lung involvement; the patient may experience chronic changes, such as nodules. Page Ref: 1301 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

7 ..

8) The nurse is teaching a patient prescribed isoniazid (INH). Which patient statement indicates that additional patient teaching is required? 1. "I will take the INH immediately after eating breakfast." 2. "I will make sure I tell all my healthcare providers that I am taking INH." 3. "Although I love beer, I will give it up while taking this medication." 4. "I will make sure I get my laboratory tests drawn to monitor my liver function." Answer: 1 Explanation: 1. For maximum effectiveness, INH should be taken one hour before meals or on an empty stomach since food interferes with the absorption of the drug. 2. To avoid drug interactions, patients should advise all healthcare providers that they are taking the medication. 3. The patient should avoid alcohol because of the harmful effects to the liver while taking this medication. 4. Because of the risk of hepatotoxicity, the patient should have baseline and monthly evaluations of liver function while on INH. Page Ref: 1300 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

8 ..

9) A patient has a chest tube inserted for a pneumothorax. What should the nurse expect when assessing the drainage system? 1. Periodic bubbling in the water seal chamber immediately after insertion 2. No evidence of tidaling 3. Vigorous bubbling in the suction control chamber 4. Large amount of bloody drainage in the drainage collection chamber Answer: 1 Explanation: 1. When a chest tube is inserted in the pleural space for a pneumothorax, the trapped air is allowed to escape and periodic bubbling is observed in the water seal as the lung reexpands. 2. The water column in the water seal should rise with inspiration and fall with expiration (tidaling). 3. There should be gentle bubbling in the suction control chamber to avoid rapid evaporation of the fluid in the chamber. 4. Large amounts of bloody drainage would be anticipated after chest tube insertion for hemothorax. Page Ref: 1312 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

9 ..

10) The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax? 1. New onset of absent breath sounds over the right lung 2. Blood pressure of 170/80 mmHg 3. Pulse oximetry readings ranging from 94% to 96% 4. Crackles and wheezing heard in both lungs Answer: 1 Explanation: 1. In a tension pneumothorax, air enters the pleural space with each breath but does not exit. Progressive accumulation of air in the pleural space leads to collapse of the lung on the affected side and hypoxia. As a result, the patient would have absent breath sounds on the affected side. 2. As the pressure in the thorax increases, cardiac output declines and the patient becomes hypotensive. 3. A pulse oximetry reading of 94% demonstrates adequate oxygenation. 4. The patient would have decreasing breath sounds on the affected side rather than adventitious sounds (crackles and wheezes). Page Ref: 1311 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

10 ..

11) The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax? 1. Hyperresonance to percussion at the apex of the left lung 2. Dullness to percussion at the base of the left lung 3. Crackles throughout the left lung 4. Shallow breathing Answer: 1 Explanation: 1. In pneumothorax, the percussion tone is hyperresonant due to the trapped air in the pleural space. 2. Dullness to percussion is suggestive of fluid accumulation, such as in hemothorax. 3. Crackles in the left lung suggest fluid accumulation in the alveoli. 4. Shallow breathing can occur but is not specific to pneumothorax. It would also be seen in rib fractures and flail chest. Page Ref: 1310 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

11 ..

12) The nurse caring for a patient diagnosed with lung cancer determines that the patient might be experiencing superior vena cava syndrome. What did the nurse assess to make this clinical decision? 1. Face and neck swelling 2. Hourly urine outputs 250 to 500 mL 3. Calcium level of 14.0 mg/dL 4. Flat jugular veins Answer: 1 Explanation: 1. Superior vena cava (SVC) syndrome is an oncologic emergency and occurs when a lung tumor obstructs the SVC. This results in facial swelling, hands, arms, and neck swelling, distended jugular veins, cyanosis of the upper torso and dyspnea. 2. Hourly urine outputs of 250 to 500 mL/hr are suggestive of the complication known as syndrome of inappropriate ADH (SIADH). 3. A calcium level of 14.0 mg/dL is considered hypercalcemia, which is a metabolic emergency associated with lung cancers. 4. SVC syndrome results in distended jugular veins. Page Ref: 1323 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

12 ..

13) A patient states, "I've been sick for days, and all the doctor does is take a chest x-ray, hand me prescriptions, and tell me I have bronchitis." What should the nurse consider about this patient's treatment? 1. Appropriate for the diagnosis 2. Should include more diagnostic tests 3. Inadequate for the diagnosis of bronchitis 4. Should include hospitalization Answer: 1 Explanation: 1. The diagnosis of acute bronchitis typically is based on the history and clinical presentation. A chest x-ray may be ordered to rule out pneumonia, because the presenting manifestations can be similar. Many physicians prescribe a broad-spectrum antibiotic such as erythromycin or penicillin, because approximately 50% of acute bronchitis is bacterial in origin. 2. Other diagnostic testing and hospitalization are rarely indicated. 3. The diagnosis of acute bronchitis typically is based on the history and clinical presentation. 4. Other diagnostic testing and hospitalization are rarely indicated. Page Ref: 1280 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

13 ..

14) A patient who is diagnosed with primary atypical pneumonia reports not feeling "sick." What would be the nurse's best response? 1. "Give it a few days and you will." 2. "You're lucky." 3. "You must be recovering from the illness." 4. "This type of pneumonia is usually mild in its effects." Answer: 4 Explanation: 1. Predicting that the patient should expect to feel bad soon is not an appropriate response. 2. Predicting that the patient should feel "lucky" is not an appropriate response. 3. Since the illness is typically mild, the patient may not feel very sick while in the acute phase, not just during recovery. 4. Young adults are the primary affected population. Primary atypical pneumonia is highly contagious with manifestations similar to those of viral pneumonia; systemic manifestations of fever, headache, myalgias, and arthralgias often predominate. Because of the typically mild nature and predominant systemic manifestations, mycoplasmal and viral pneumonia are often referred to as "walking pneumonias." Page Ref: 1283 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

14 ..

15) A patient who was admitted with symptoms of hypoxia is changed from a face mask to a nasal cannula for oxygen delivery. How should the nurse classify this patient's health status? 1. Deteriorating 2. Improving 3. Stabilizing 4. Compounded with another health issue Answer: 2 Explanation: 1. The nasal cannula is comfortable and does not interfere with eating or talking. A simple face mask delivers 40% to 60% oxygen concentrations with flow rates of 5 to 8 L/min. This patient's condition is most likely improving. 2. This patient's condition is most likely improving. Low-flow oxygen delivery systems include the nasal cannula, simple face mask, partial rebreathing mask, and nonrebreathing mask. A nasal cannula can deliver 24% to 45% oxygen concentrations with flow rates of 2 to 6 L/min. The nasal cannula is comfortable and does not interfere with eating or talking. 3. There is not enough information to determine if this patient's condition is stabilizing. 4. There is no evidence that this patient has another health issue. Page Ref: 1286 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

15 ..

16) A hospitalized patient is diagnosed with severe acute respiratory syndrome (SARS). What action should the nurse implement immediately? 1. Standard precautions 2. Standard precautions and droplet precautions 3. Standard precautions and contact precautions 4. Standard, contact, and airborne precautions Answer: 4 Explanation: 1. Standard precautions should be implemented in addition to contact and airborne precautions. 2. Standard precautions should be implemented in addition to contact and airborne precautions. 3. Standard precautions should be implemented in addition to contact and airborne precautions. 4. Because healthcare workers are at risk for developing sudden acute respiratory syndrome (SARS) after caring for infected patients, infection control precautions should be immediately instituted when SARS is suspected. Standard precautions should be implemented in addition to contact and airborne precautions. Page Ref: 1292 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

16 ..

17) A patient with a lung abscess is being discharged from the hospital. What should be included in this patient's discharge instructions? 1. Complete the entire prescription of antibiotics. 2. Expect symptoms to become worse. 3. Return to routine activities of daily living. 4. Lung abscesses rarely cause other problems once treatment is started. Answer: 1 Explanation: 1. Emphasize the importance of completing the entire course of therapy to eliminate the infecting organisms. Teach about the medication, including its name, dose, and desired and adverse effects. 2. Stress the need to contact the physician if symptoms do not improve or if they become worse. 3. Most lung abscesses are successfully treated with antibiotics; however, treatment may last up to one month or more. 4. Infection from lung abscess can spread not only to lung and pleural tissue but systemically, and cause sepsis. Page Ref: 1293 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

17 ..

18) A patient who is on isoniazid (INH) for pulmonary tuberculosis reports not wanting to take the medication because it makes the fingers burn. Which side effect is this patient experiencing? 1. A common side effect of isoniazid (INH) that will go away after completing the medication 2. A common side effect of isoniazid (INH) that can be treated with pyridoxine 3. A long-term complication of isoniazid (INH) that has no treatment 4. A common complication of isoniazid (INH) that can be treated with vitamin B 12 injections Answer: 2 Explanation: 1. This is correct but pyridoxine or vitamin B6 often is prescribed to prevent this adverse effect. 2. Peripheral neuropathy numbness, tingling, or a burning sensation of the extremities may occur with isoniazid (INH). Pyridoxine or vitamin B6 often is prescribed to prevent this adverse effect. 3. This adverse effect is treatable. 4. Pyridoxine or vitamin B6 often is prescribed to prevent this adverse effect. Page Ref: 1300 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

18 ..

19) A patient who had a Mantoux test for tuberculosis two days ago has a 2 mm area of erythema at the site of the test. How should this finding be identified? 1. Negative 2. Positive for tuberculosis 3. Follow up with a tine test 4. Unable to be determined Answer: 1 Explanation: 1. Intradermal PPD or Mantoux test is read within 48 to 72 hours, the peak reaction period, and recorded as the diameter of induration (raised area, not erythema) in millimeters. The area on the patient is erythematous, not an induration. No follow up is needed, as this patient's response is by definition a negative one. 2. A 2 mm area of erythema at the site of the test is negative for tuberculosis. 3. A 2 mm area of erythema at the site of the test is not an indication of the need for a tine test. 4. A 2 mm area of erythema at the site of the test is negative for tuberculosis. Page Ref: 1298 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

19 ..

20) A patient reports receiving the bacilli Calmette-Guérin (BCG) vaccination as a child. How should the nurse expect this patient to be screened for tuberculosis? 1. Tine test 2. Mantoux test 3. Tine and Mantoux tests 4. Chest x-ray Answer: 4 Explanation: 1. After vaccination with BCG, a positive reaction to tuberculin testing is common. 2. After vaccination with BCG, a positive reaction to tuberculin testing is common. 3. After vaccination with BCG, a positive reaction to tuberculin testing is common. 4. Periodic chest x-rays may be required for screening purposes. Page Ref: 1299 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.

20 ..

21) A patient who is taking rifampin (Rifadin) as part of treatment for tuberculosis asks about making an appointment for a urologist because the urine is "bright orange." What should the nurse realize this patient is experiencing? 1. A secondary urinary tract infection 2. A common side effect of rifampin therapy 3. The onset of a kidney stone 4. Early renal failure Answer: 2 Explanation: 1. Bright orange urine is not a symptom for urinary tract infection. 2. Rifampin (Rifadin) causes body fluids, including sweat, urine, saliva, and tears, to turn redorange. This is not harmful. 3. Bright orange urine is not a symptom of a kidney stone. 4. Bright orange urine does not indicate early renal failure. Page Ref: 1300 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

21 ..

22) The nurse is providing care to a patient with pulmonary tuberculosis. What should the nurse do to ensure personal protection while caring for this patient? 1. Wear a gown and eye goggles. 2. Wear a gown and surgical mask. 3. Wear a gown and HEPA mask. 4. Wear a gown and sterile gloves. Answer: 3 Explanation: 1. A gown and eye goggles are not sufficient personal protective devices for this condition. 2. Surgical masks are ineffective to filter droplet nuclei, which necessitates the use of protective devices capable of filtering bacteria and particles smaller than 1 micron. 3. The Occupational Safety and Health Administration (OSHA) requires use of a HEPA-filtered respirator for protection against occupational exposure to tuberculosis. 4. A gown and sterile gloves are not sufficient personal protection devices for this condition. Page Ref: 1303 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

22 ..

23) A patient is diagnosed with histoplasmosis. What element of this patient's history would help explain the reason for the disease? 1. Lives in a city with chemical plants 2. Drives a vehicle that uses diesel fuel 3. Is an electrical engineer 4. Works on a chicken farm Answer: 4 Explanation: 1. Chemical plants do not generally contribute to histoplasmosis infection. 2. Diesel fluid does not contain histoplasmosis. 3. Exposure to electricity does not cause histoplasmosis. 4. Histoplasmosis, an infectious disease caused by Histoplasma capsulatum, is the most common fungal lung infection in the United States. The organism is found in the soil and is linked to exposure to bird droppings and bats. Page Ref: 1306 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

23 ..

24) A patient with lung cancer is demonstrating signs of complete tumor response after two courses of chemotherapy. What should the nurse conclude that this response indicates? 1. A long-term survival from the disease 2. An indication that radiation therapy is needed 3. An indication that surgery can be performed 4. A contraindication for further chemotherapy Answer: 1 Explanation: 1. Fifty percent of patients with tumors at early stages achieve complete tumor remission with combination chemotherapy. When a complete tumor response is achieved in the first few cycles of chemotherapy, the chances for long-term survival are much greater. 2. This is not an indication of the need for radiation. 3. Surgery is not warranted from this finding. 4. This is not a contraindication for further chemotherapy. Page Ref: 1325 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

24 ..

25) A patient who is receiving radiation therapy for lung cancer complains of ongoing fatigue. What should be included in the teaching for this patient? 1. This is a complication of radiation therapy and will continue for years. 2. There is nothing that can help the fatigue. 3. Frequent rest periods and good nutrition can help with the fatigue. 4. Restricting caloric intake often helps with the fatigue. Answer: 3 Explanation: 1. The fatigue effects due to radiation do not last for years, only for the duration of treatment. 2. Measures can be taken to help with fatigue. 3. Adequate rest and nutrition are important to alleviate the symptoms of radiation fatigue, which is common in patients who are receiving radiation therapy for lung cancer. The fatigue is generally temporary. 4. Restricting calories would only contribute to continued fatigue. Page Ref: 1327 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

25 ..

26) A patient is diagnosed with pleurisy. What should the nurse suggest to the patient to alleviate the associated chest pain from this disorder? 1. Instructing the patient to take the prescribed analgesic only when the pain is severe 2. Teaching the patient how to splint the affected area when coughing 3. Advising the patient to maintain bed rest 4. Warning the patient to expect a fever to develop Answer: 2 Explanation: 1. Provide information about prescription and nonprescription NSAIDs and analgesics, including the drug ordered, how to use it, and its desired and possible adverse effects. 2. Nursing care for the patient with pleuritis should include positioning and splinting the chest while coughing. 3. Bed rest is not indicated for treatment of pleurisy. 4. Discuss symptoms to report to the physician: increased fever, productive cough, difficulty breathing, or shortness of breath. Page Ref: 1307 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

26 ..

27) A young adult patient who is asking questions about smoking cessation plans to take a scuba diving class. Which health problem is this patient at risk for developing? 1. Pleural effusion 2. Pleurisy 3. Pneumothorax 4. Hemothorax Answer: 3 Explanation: 1. The patient's age, smoking status, and scuba diving interest do not increase the risk for developing a pleural effusion. 2. The patient's age, smoking status, and scuba diving interest do not increase the risk for developing pleurisy. 3. Certain activities increase the risk of spontaneous pneumothorax, such as high-altitude flying and rapid decompression during scuba diving. 4. The patient's age, smoking status, and scuba diving interest do not increase the risk for developing a hemothorax. Page Ref: 1309 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

27 ..

28) The nurse observes air bubbles in a patient's chest tube water seal chamber. How should the nurse interpret this finding? 1. Normal 2. An emergency 3. An indication that the pneumothorax is worsening 4. An indication to remove the chest tube Answer: 1 Explanation: 1. Periodic air bubbles in the water-seal chamber are normal and indicate that trapped air is being removed from the chest. 2. This is not an emergency situation. 3. This is not a situation that indicates a worsening condition. 4. The nurse would need a physician's order to remove a chest tube. The patient still needs the chest tube in place. Page Ref: 1312 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

28 ..

29) During the assessment of a patient's respiratory status, the nurse notes paradoxical lung movements. Which health problem should the nurse suspect is occurring with this patient? 1. Flail chest 2. Pleurisy 3. Pneumothorax 4. Pneumonia Answer: 1 Explanation: 1. Physiologic function of the chest wall is impaired as the flail segment is sucked inward during inhalation and moves outward with exhalation. This is known as paradoxic movement. 2. Paradoxic movement is not an indicator of pleurisy. 3. Paradoxic movement is not an indicator of pneumothorax. 4. Paradoxic movement is not an indicator of pneumonia. Page Ref: 1315 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.3 Describe the pathophysiology and manifestations of trauma of the chest or lung, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

29 ..

30) The nurse is providing care to a patient with a differential diagnosis of carbon monoxide poisoning. Which assessment finding would be consistent with this diagnosis? Select all that apply. 1. Cherry-red mucous membranes 2. Circumoral pallor 3. Diarrhea 4. Nausea 5. Dizziness Answer: 1, 4, 5 Explanation: 1. A characteristic "cherry-red" color of the skin and mucous membranes may be seen with carbon monoxide poisoning. 2. Circumoral pallor is not seen with carbon monoxide poisoning. 3. Diarrhea is not a symptom of carbon monoxide poisoning. 4. The manifestations of carbon monoxide poisoning depend on the level of carboxyhemoglobin saturation. When hemoglobin is 10% to 20% saturated with carbon monoxide, symptoms include nausea. 5. The manifestations of carbon monoxide poisoning depend on the level of carboxyhemoglobin saturation. When hemoglobin is 10% to 20% saturated with carbon monoxide, symptoms include dizziness. Page Ref: 1319 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.3 Describe the pathophysiology and manifestations of trauma of the chest or lung, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

30 ..

31) A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Select all that apply. 1. Hypertension 2. Distended neck veins 3. Bradycardia 4. Absent breath sounds on the affected side 5. Tracheal deviation toward unaffected side Answer: 2, 4, 5 Explanation: 1. Manifestations of a tension pneumothorax include hypotension. 2. Manifestations of a tension pneumothorax include distended neck veins. 3. Manifestations of a tension pneumothorax include tachycardia. 4. Manifestations of a tension pneumothorax include absent breath sounds on affected side. 5. Manifestations of a tension pneumothorax include tracheal deviation toward unaffected side. Page Ref: 1311 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

31 ..

32) A child diagnosed with pneumonia has been prescribed erythromycin, 45 mg per day for every 1 kilogram of body weight. The patient weighs 46 pounds. The physician asks that the patient receive the medication in three equal doses throughout the day. Calculate how much medication the patient should receive per each dose. ________ mg Record your answer rounding to the nearest whole number. Answer: 314 Explanation: The patient weighs 46 pounds and there are 2.2 pounds per 1 kilogram. The patient weighs 20.909 kilograms. The patient is supposed to receive 45 mg per every kilogram of body weight. The patient should receive 940.909 mg of erythromycin each day. When this dose is divided into three equal doses, it is 313.64 mg per dose. When rounded to a whole number, this is 314 mg. Page Ref: 1285 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.

32 ..

33) The nurse is caring for victims of bioterrorism who were exposed to inhalation anthrax. After assessment, it is determined that 350 people were exposed to the potentially deadly spore. Knowing that this disease has a 45% mortality rate, how many patients should the nurse expect to recover from this illness? Record your answer rounding to the nearest whole number. Answer: 193 Explanation: If 350 patients were exposed, and the mortality rate is 45%, then 55% of the patients are expected to recover. The nurse should multiply 350 × 55% = 192.5 or 193 patients. Page Ref: 1306 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

33 ..

34) A patient has developed pulmonary tuberculosis. Rank the findings in order of occurrence based on the normal progression of this disease. Place the findings in the order in which they occur. Choice 1. The patient begins to feel better. Choice 2. The patient is admitted to the hospital for treatment of pulmonary tuberculosis. Choice 3. The patient does not complain of any symptoms associated with pulmonary tuberculosis. Choice 4. The patient visits the physician's office with complaints of fatigue, night sweats, and has lost 10 pounds over the last 3 months. Choice 5. The patient's purified protein derivative test is positive. The patient develops a cough with blood-tinged sputum. A chest x-ray indicates the presence of a cavitary lesion. Answer: 3, 4, 5, 2, 1 Explanation: The initial infection causes very few, if any symptoms. The patient may visit a physician with vague complaints of fatigue, weight loss, night sweats, and fevers. The physician will most likely order a PPD (purified protein derivative) test to determine if the patient has ever been exposed to tuberculosis. The patient may develop hemoptysis. An x-ray may indicate the presence of cavitary lesion. The patient will most likely be admitted to the hospital for treatment of pulmonary tuberculosis. The patient will most likely begin to feel better after treatment. Page Ref: 1297 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

34 ..

35) A patient is recovering from surgery for lung cancer. Which action should the nurse take when caring for this patient? Select all that apply. 1. Assess respiratory system at least every four hours. 2. Restrict the use of pain medication. 3. Provide frequent small meals. 4. Use strict aseptic technique. 5. Assist with early ambulation. Answer: 1, 3, 4, 5 Explanation: 1. The nurse should perform a respiratory assessment at least every four hours. 2. Narcotic pain medications should be offered after thoracic surgery to ensure that the patient can perform pulmonary rehabilitation exercises such as coughing, deep breathing, and incentive spirometry. The patient who is using narcotic pain medications to achieve pain control must be monitored for respiratory depression so that it can be treated. 3. Frequent small meals should be provided to ensure for wound healing and adequate nutritional status. 4. All care should be provided using aseptic technique to prevent the development of infections. 5. Early ambulation helps to prevent postoperative complications. Page Ref: 1326 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 36.4 Describe the pathophysiology and manifestations of lung cancer, and outline the interprofessional care and nursing care of patients with this disease. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

35 ..

36) After reviewing the medical history, the nurse suspects that an older patient would benefit from another dose of the pneumococcus vaccination. What information did the nurse use to make this clinical decision? Select all that apply. 1. Initial vaccination at age 55 2. Taking medications for hypertension 3. Ongoing treatment for prostate cancer 4. History of two hip replacement surgeries 5. Beginning dialysis for chronic renal failure Answer: 1, 3, 5 Explanation: 1. Pneumococcal vaccine, made of antigens from 23 types of pneumococcus, usually imparts lifetime immunity with a single dose. A one-time revaccination is recommended for selected populations, including people over age 65 who were immunized more than 5 years previously and before age 65. 2. Being treated for hypertension does not increase this patient's risk of developing pneumonia. 3. Pneumococcal vaccine, made of antigens from 23 types of pneumococcus, usually imparts lifetime immunity with a single dose. A one-time revaccination is recommended for selected populations, including people with an immunosuppressive condition such as cancer. 4. Having joint replacement surgery does not increase this patient's risk of developing pneumonia. 5. Pneumococcal vaccine, made of antigens from 23 types of pneumococcus, usually imparts lifetime immunity with a single dose. A one-time revaccination is recommended for selected populations, including people with chronic renal failure. Page Ref: 1285 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with ventilation disorders.

36 ..

37) The nurse is preparing to assess a patient admitted for treatment of bilateral pleural effusions. On what should the nurse focus when assessing this patient? Select all that apply. 1. Urine output 2. Cardiac rate and rhythm 3. Joint function and mobility 4. Muscle tone and movement 5. Peripheral pulses and edema Answer: 1, 2, 3, 5 Explanation: 1. Excess pleural fluid may be either transudate, formed when capillary pressure is high or plasma proteins are low, or exudate, the result of increased capillary permeability. Pleural effusion occurs in renal failure. The nurse should evaluate the patient's urine output. 2. Excess pleural fluid may be either transudate, formed when capillary pressure is high or plasma proteins are low, or exudate, the result of increased capillary permeability. Heart failure is the most common precipitating factor in transudate formation. The patient's heart rate and rhythm should be evaluated. 3. Excess pleural fluid may be either transudate, formed when capillary pressure is high or plasma proteins are low, or exudate, the result of increased capillary permeability. Exudate, a protein-rich fluid, is seen with inflammatory processes such as systemic inflammation caused by rheumatoid arthritis. The nurse should assess the patient's joint function and mobility. 4. Excess pleural fluid does not affect muscle tone or movement. 5. Excess pleural fluid may be either transudate, formed when capillary pressure is high or plasma proteins are low, or exudate, the result of increased capillary permeability. Heart failure is the most common precipitating factor in transudate formation. The patient's peripheral pulses and presence of edema should be evaluated. Page Ref: 1307-1308 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with ventilation disorders.

37 ..

38) The nurse is preparing a patient for a thoracentesis to drain an empyema. What should the nurse instruct the patient about this procedure? Select all that apply. 1. You will have a chest x-ray after the procedure. 2. You will lie on the unaffected side for 1 hour after the procedure. 3. You will have general anesthesia for pain control during the procedure. 4. You will be seated, learning forward with arms and head supported with an overbed table. 5. You will be permitted to resume normal activities after 1 hour if no evidence of adverse effects occurs. Answer: 1, 2, 4, 5 Explanation: 1. After the procedure a chest x-ray is ordered to detect possible pneumothorax. 2. After the procedure the patient will be positioned on the unaffected side for 1 hour. This allows the pleural puncture to heal. 3. Only local anesthesia is used in this procedure. 4. The patient will be positioned upright for the procedure, leaning forward with arms and head supported on an anchored, overbed table. This position spreads the ribs, enlarging the intercostal space for needle insertion. 5. After the procedure, normal activities generally can be resumed after 1 hour if no evidence of pneumothorax or other complication is present. The puncture wound of thoracentesis heals rapidly. Page Ref: 1309 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 36.2 Describe the pathophysiology and manifestations of disorders of the pleura, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with ventilation disorders.

38 ..

39) A patient is diagnosed with Legionella pneumophila. Which antibiotic should the nurse expect to be prescribed for this patient? Select all that apply. 1. Rifampin 2. Macrolide 3. Prednisone 4. Erythromycin 5. Fluoroquinolone Answer: 1, 2, 5 Explanation: 1. The antibiotics of choice for Legionella pneumophila include rifampin. 2. The antibiotics of choice for Legionella pneumophila include a macrolide. 3. Prednisone is used to treat Pneumocystis. 4. Erythromycin is used to treat Mycoplasma pneumonia. 5. The antibiotics of choice for Legionella pneumophila include fluoroquinolones. Page Ref: 1285 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 36.1 Describe the pathophysiology and manifestations of infectious and inflammatory ventilation disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with ventilation disorders.

39 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 37 Nursing Care of Patients with Gas Exchange Disorders 1) A patient with an acute exacerbation of emphysema is prescribed 60 mg of methylprednisolone per intravenous push. The medication is available from the pharmacy as 40 mg per 1 mL. How many milliliters of the medication should the nurse administer? Calculate to the nearest tenth decimal point. Answer: 1.5 Explanation: Using the equation Dosage Available/Dosage Prescribed, 60 mg/40 mg × 1 mL = 6/4 × 1 = 1.5 mL. The nurse will need to administer 1.5 mL of methylprednisolone. Page Ref: 1349 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders. 2) A patient who nearly drowned is diagnosed with pulmonary edema and is prescribed furosemide 40 mg slow intravenous push. The medication available is a vial containing 100 mg/10 mL. How many milliliters of the medication should the nurse administer? Calculate the exact dose. Answer: 4 Explanation: The nurse can use the equation Dosage Required/Dosage Available × mL, or 40 mg/100 mg × 10 mL = 4/10 × 10 = 0.4 × 10 = 4 mL. The nurse will administer 4 mL of the medication. Page Ref: 1382 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. 1 ..

MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders. 3) A patient who has been feeling more anxious since the recent and unexpected death of a spouse is experiencing an acute asthma attack. Rank the following events in the most likely order of occurrence. Place the five events in the correct order. Choice 1. The patient states, "I feel like my throat is closing off and I can't breathe very well." Choice 2. The patient is allergic to aspirin but unknowingly ingested a product with aspirin among its ingredients. Choice 3. The patient's respiratory rate is 32 breaths per minute and his oxygen saturation level falls from 94% to 89%. Choice 4. Inflammatory mediators are released and inflammatory cells are activated. Choice 5. The patient is taken to the hospital via an ambulance and treated with medication. Answer: 2, 4, 1, 3, 5 Explanation: Aspirin-containing products are a common pharmacologic trigger for acute asthma attacks. When a trigger is present, an acute or early response develops in the hyperreactive airways predisposed to bronchospasm. Sensitized mast cells in the bronchial mucosa release inflammatory mediators such as histamine, prostaglandins, and leukotrienes. These events lead to bronchoconstriction, airway edema, and impaired mucociliary clearance. Airway narrowing limits airflow and increases the work of breathing; trapped air mixes with inhaled air, impairing gas exchange. Hospitalization may be required to prevent the complications of an asthma attack, which include acute respiratory failure, dehydration, respiratory infection, atelectasis, pneumothorax, and cor pulmonale. Page Ref: 1336-1337 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.

2 ..

4) The nurse is providing medications to a patient with asthma. What does the nurse recognize about the use of corticosteroid inhalers for this patient? 1. They should be provided after the bronchodilator. 2. They are used only for acute asthma attacks. 3. They are used often with methylxanthines. 4. They are used to activate muscarinic receptors. Answer: 1 Explanation: 1. Corticosteroids are given after the bronchodilator, as the bronchodilator opens the airways. 2. Corticosteroids require weeks to begin to have an effect on breathing and therefore cannot be used for acute attacks. 3. Corticosteroids are usually not combined with methylxanthines but may be combined with adrenergic stimulants. 4. The anticholinergics affect the muscarinic receptors. Page Ref: 1341 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

3 ..

5) The nurse is caring for a patient who is receiving neuromuscular blocking agents and is mechanically ventilated. For which reason should the alarms on the ventilator be activated? 1. The patient cannot breathe. 2. The patient will experience oxygen toxicity. 3. The patient might have arrhythmias. 4. The patient may have reduced intrapleural pressure. Answer: 1 Explanation: 1. A patient on a ventilator and a neuromuscular blocker cannot breathe, as he or she is paralyzed. If the alarms are turned off or bypassed, the patient may die if there is a malfunction. 2. The patient will not experience oxygen toxicity. 3. The patient may experience arrhythmias, but that would occur with hypoxia. 4. The patient may have increased intrapleural pressure, which can rupture the alveoli. Page Ref: 1373 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

4 ..

6) A patient has a nasal endotracheal tube. For which complication should the nurse assess this patient? Select all that apply. 1. Tracheoesophageal fistula 2. Wound infection 3. Pressure necrosis of nares 4. Sinusitis 5. Obstruction of the tube Answer: 1, 3, 4, 5 Explanation: 1. The patient with a nasal endotracheal tube can develop a tracheoesophageal fistula from the pressure exerted against the tissues by the tube. 2. Wound infection can occur with a tracheostomy. 3. The patient with a nasal endotracheal tube can develop pressure necrosis of the nares from the pressure exerted against the tissues by the tube. 4. The patient with a nasal endotracheal tube can develop sinusitis if sinus drainage is blocked. 5. The tube can be displaced or obstructed. Page Ref: 1374 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

5 ..

7) The nurse is preparing discharge instructions for a patient recovering from acute respiratory distress syndrome (ARDS). What should be included in this teaching? Select all that apply. 1. Avoid smoking and exposure to air pollution. 2. Practice lifestyle modifications to reduce oxygen demands. 3. Restrict fluids to prevent congestive heart failure (CHF). 4. Get the influenza immunization annually. 5. Avoid large crowds. Answer: 1, 2, 4 Explanation: 1. Pollution and cigarette smoke can further damage already traumatized lung tissue and should be avoided. 2. Lifestyle modifications to conserve energy and reduce oxygen demands are necessary, as lung tissues are still recovering from the damage of the disease process. Exertional dyspnea will continue to increase if additional demands are made on the pulmonary and cardiovascular system. 3. Fluids are needed to rehydrate lung tissue and to enhance renal function by diluting wastes from tissue repair. CHF from right-sided failure is possible, but not usually in the recovery phase (after discharge from the hospital). 4. Immunizations for pneumonia and flu are encouraged to minimize additional insults to lung tissue, as the entire physical status of lung tissue will require up to 6 months to recover. 5. These patients are not immunocompromised and can attend large-crowd events, such as church services, without risk. Page Ref: 1381 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

6 ..

8) A patient is admitted with pulmonary edema. What is important for the nurse to assess first when completing the patient's history? Select all that apply. 1. Cardiac history 2. Pulmonary history 3. Renal and cardiac history 4. Pulmonary and renal history 5. Recent drug use and past vaccination record Answer: 1, 2 Explanation: 1. Attempting to determine a cause for pulmonary edema will assist the healthcare team in providing appropriate care. Cardiogenic and noncardiogenic pulmonary edemas require different approaches to treatment. 2. Attempting to determine a cause for pulmonary edema will assist the healthcare team in providing appropriate care. Cardiogenic and noncardiogenic pulmonary edemas require different approaches to treatment. 3. The renal history will be addressed but is not a priority assessment. The cardiac history will be assessed. 4. The renal history will be addressed but is not a priority assessment. The pulmonary history will be assessed. 5. Recent drug use and the past vaccination record are important but not a first area to assess for the patient. Page Ref: 1371 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.

7 ..

9) A patient diagnosed with sepsis suddenly develops dyspnea, crackles, agitation, and confusion. Which health problem should the nurse suspect this patient is developing? 1. Noncardiogenic pulmonary edema 2. Right-sided heart failure 3. Left-sided heart failure 4. Constrictive pericarditis Answer: 1 Explanation: 1. Sepsis is a condition associated with acute respiratory distress syndrome (ARDS). Manifestations of ARDS include dyspnea, crackles, agitation, and confusion, which are associated with noncardiogenic pulmonary edema. 2. These are not manifestations of right-sided heart failure, which is a cardiogenic cause for pulmonary edema. 3. These are not manifestations of left-sided heart failure, which is a cardiogenic cause for pulmonary edema. 4. These are not manifestations of constrictive pericarditis, which is a cardiogenic cause for pulmonary edema. Page Ref: 1382 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.

8 ..

10) A patient being mechanically ventilated develops hypotension after the respiratory therapist implements the most recent physician orders. Which ventilator mode should the nurse suspect has caused this change in the patient's status? 1. PEEP 2. SIMV mode 3. Assist-control mode 4. Pressure-control mode Answer: 1 Explanation: 1. When PEEP is applied, intrathoracic pressure increases further; this can significantly decrease venous return, ventricular filling, stroke volume, and cardiac output. Manifestations of decreased cardiac output include hypotension. Increasing PEEP levels can cause declining blood pressure. 2. Hypotension is not commonly caused by the adjustment of the SIMV mode on the ventilator. 3. Hypotension is not commonly caused by the adjustment of the assist-control mode on the ventilator. 4. Hypotension is not commonly caused by the adjustment of the pressure-control mode on the ventilator. Page Ref: 1378 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

9 ..

11) A patient is being mechanically ventilated with SIMV at a rate of 25 breaths per minute. Why should the nurse question this setting? 1. The rate could be too high for this mode. 2. The patient would be more comfortable with a different mode. 3. The patient is not receiving enough sedation. 4. SIMV is always used in combination with PEEP. Answer: 1 Explanation: 1. SIMV is usually set so that the patient can breathe over the set rate to exercise the respiratory muscles. A rate of 25 breaths per minute would not allow this and could also establish auto PEEP. 2. The patient would not necessarily be more comfortable with a different mode; SIMV is the most commonly used mode in an ICU setting. 3. Too much sedation is contraindicated in SIMV, to allow the patient to initiate breaths on his or her own. 4. PEEP can be used with any of the modes. Page Ref: 1375 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

10 ..

12) A patient being mechanically ventilated requires increasing PEEP for worsening ARDS. The order for PEEP is now at 20 cm of H2O. For which finding should the nurse contact the healthcare provider? 1. Lung sounds greater on one side than the other 2. Lung sounds with crackles 3. Diminished peripheral pulses 4. High-pressure alarm Answer: 1 Explanation: 1. A potential complication from increasing PEEP is a pneumothorax. The nurse needs to be alert to diminishing or absent lung sounds on one side of the chest. 2. Crackles would not be related to the complication that may develop in this patient. 3. Diminished peripheral pulses would not be related to the complication that may develop in this patient. 4. A low-pressure alarm would sound if the patient developed the likely complication. Page Ref: 1377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

11 ..

13) A patient being mechanically ventilated suddenly develops cardiac dysrhythmias from increasingly higher PEEP. What underlying issue should the nurse suspect in this patient? 1. Decreased cardiac output and acidosis 2. Increased cardiac output and alkalosis 3. Decreased cardiac output and renal failure 4. Increased cardiac output and electrolyte disturbance Answer: 1 Explanation: 1. Increasingly higher PEEP with decreased cardiac output and acidosis may predispose the patient to cardiac arrhythmias. 2. Increased cardiac output does not occur with PEEP. 3. This is not the most likely underlying issue. 4. This is not the most likely underlying issue. Page Ref: 1378 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

12 ..

14) A patient being mechanically ventilated has the following ventilator settings: SIMV 16, PEEP 20 cm of H2O, FiO2 45%, and tidal volume .450 L. What concern should the nurse have for this patient? 1. Barotrauma 2. Volutrauma 3. Sinusitis 4. Oxygen toxicity Answer: 1 Explanation: 1. This patient is at risk for barotrauma due to the high PEEP levels. 2. The tidal volume is within a standard setting. 3. Sinusitis is a potential complication of ventilated patients, but this patient should not have a higher risk for this. 4. The oxygen setting at 45% will not cause oxygen toxicity in this patient. Page Ref: 1377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.

13 ..

15) The chest x-ray of a patient who was recently intubated shows the endotracheal tube located in the right mainstem bronchus. What action should be taken at this time? 1. The tube needs to be withdrawn slightly. 2. The tube needs to be inserted further. 3. The tube is correctly placed. 4. The tube is incorrectly attached to the ventilator. Answer: 1 Explanation: 1. The right mainstem bronchus is easy to intubate due to the anatomy of the lung. If the tube is in the right bronchus, it will need to be withdrawn slightly so that both lungs can be ventilated. 2. The tube does not need to be inserted further. 3. The tube is not correctly placed. 4. This finding does not mean that the tube is incorrectly attached to the ventilator. Page Ref: 1380 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

14 ..

16) A patient who is intubated is exhibiting rhonchi and has a pulse oximeter of 92%, soft abdomen, heart rate of 88 bpm, and blood pressure of 98/54 mmHg. Which should the nurse complete first? 1. Suction the patient. 2. Contact the healthcare provider. 3. Increase the oxygen. 4. Start dopamine. Answer: 1 Explanation: 1. The presence of rhonchi suggests the patient needs to be suctioned. 2. The assessment data does not require contacting the physician. 3. The assessment data does not require increasing the oxygen. 4. The relative hypotension can be caused by the ventilation and does not require dopamine for blood pressure support. Page Ref: 1380 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

15 ..

17) The nurse is caring for a patient who is intubated and being mechanically ventilated. Which prescription should the nurse question for this patient? 1. Endotracheal suctioning every hour 2. Endotracheal suctioning as needed 3. NPO status while patient is ventilated 4. Intake and output every 4 hours Answer: 1 Explanation: 1. Suctioning should always be based on patient need and not routinely ordered. 2. PRN suctioning is appropriate for this patient. 3. NPO status is appropriate for the ventilated patient. 4. Intake and output monitoring is appropriate for this patient. Page Ref: 1380 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

16 ..

18) A patient being mechanically ventilated is exhibiting hypoxia, with a pulse oximeter reading of 88%. What should the nurse do if adventitious lung sounds are auscultated? 1. Suction the patient. 2. Contact the healthcare provider. 3. Turn the patient to one side. 4. Silence the alarm. Answer: 1 Explanation: 1. When the tubing integrity is intact and the pulse oximeter reading falls to 88% with adventitious breath sounds, the patient needs to be suctioned. 2. The physician will not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia. 3. Turning the patient on the side has no purpose. 4. Silencing the alarm will not resolve the issue. Page Ref: 1380 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

17 ..

19) The family of a mechanically ventilated patient receiving a chest tube asks why the tube is necessary. How should the nurse respond? 1. "The chest tube helps to decompress the lung and prevents further complications." 2. "The chest tube helps the patient breathe more easily when on a ventilator." 3. "The chest tube is an elective procedure that many physicians like to perform." 4. "Placement of the chest tube requires surgery." Answer: 1 Explanation: 1. The chest tube is indicated for a pneumothorax that can be spontaneous or brought on by increasingly higher PEEP. 2. A chest tube does not directly assist a patient with breathing more easily on a ventilator, but it does allow the lung to expand more fully, which helps with the patient's overall oxygenation. 3. The insertion of a chest tube is not an elective procedure. 4. Insertion of a chest tube is most often performed at the bedside, not in surgery. Page Ref: 1377 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

18 ..

20) The nurse instructs a patient on the use of a metered-dose inhaler for asthma medications. To demonstrate understanding of the instructions, in which order should the patient selfadminister this medication? Place in order the steps of the process. Choice 1. Rinse the mouth. Choice 2. Exhale slowly and completely. Choice 3. Shake the canister vigorously for 3 to 5 seconds. Choice 4. Press and hold the canister down while inhaling deeply and slowly for 3 to 5 seconds. Choice 5. Hold the breath for 10 seconds, release the pressure on the container, remove from the mouth, and exhale. Answer: 3, 2, 4, 5, 1 Explanation: The canister is shaken before the medication is administered. The patient exhales before administering the medication. The canister is pressed and held down while the patient inhales. This step takes 3 to 5 seconds. The breath is held for 10 seconds after the medication is administered. Then the pressure on the canister is released and the canister is removed from the mouth. The patient can then exhale. The mouth is rinsed after the medication is inhaled. Page Ref: 1339 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

19 ..

21) The nurse realizes that the medication tiotropium bromide (Spiriva) is contraindicated for a patient with chronic obstructive pulmonary disease (COPD). What information in the patient's medical history led to this clinical decision? Select all that apply. 1. The patient is being treated for glaucoma. 2. The patient uses a topical steroid for psoriasis. 3. The patient attends physical therapy three times a week. 4. The patient is taking medication for prostatic hypertrophy. 5. The patient limits the intake of dietary fats for weight loss. Answer: 1, 4 Explanation: 1. Contraindications to tiotropium bromide (Spiriva) include glaucoma. 2. Tiotropium bromide (Spiriva) is not contraindicated with a topical steroid. 3. Tiotropium bromide (Spiriva) is not contraindicated in a patient attending physical therapy. 4. Contraindications to tiotropium bromide (Spiriva) include prostatic hypertrophy. 5. This medication is not contraindicated with a low-fat diet. Page Ref: 1341 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

20 ..

22) During an assessment the nurse suspects that a patient has chronic bronchitis. On what assessment finding is the nurse basing this clinical decision? Select all that apply. 1. Barrel chest 2. Smoking 1 ppd 3. Diminished breath sounds 4. Persistent productive cough 5. Wheezes and rhonchi lung sounds Answer: 2, 4, 5 Explanation: 1. Barrel chest is associated with emphysema. 2. Smoking is associated with chronic bronchitis. 3. Diminished breath sounds are associated with emphysema. 4. A persistent and productive cough is associated with chronic bronchitis. 5. The adventitious breath sounds of wheezing and rhonchi are associated with chronic bronchitis. Page Ref: 1347 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

21 ..

23) A patient recovering from a lung transplant will have denervation of the lung tissue. What should the nurse include when planning this patient's care? Select all that apply. 1. Administering mucolytics every 2 hours. 2. Performing postural drainage twice a shift. 3. Ensuring oxygen delivery is below 2 L. 4. Scheduling deep breathing and coughing every 2 hours. 5. Positioning for chest vibration and percussion twice per shift. Answer: 2, 4, 5 Explanation: 1. Mucolytics will not help with denervation of the lung tissue. 2. Denervation of the transplanted lung eliminates the usual cough stimuli. Regularly scheduled postural drainage is important to prevent accumulation of secretions. 3. Oxygen will not help with denervation of the lung tissue. 4. Denervation of the transplanted lung eliminates the usual cough stimuli. Regularly scheduled coughing and deep breathing are important to prevent accumulation of secretions. 5. Denervation of the transplanted lung eliminates the usual cough stimuli. Regularly scheduled chest vibration and percussion are important to prevent accumulation of secretions. Page Ref: 1351 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

22 ..

24) The nurse instructs a patient with chronic obstructive pulmonary disease (COPD) on the huff cough technique. Which observation indicates that teaching has been effective? Select all that apply. 1. The patient coughs twice. 2. The patient leans forward. 3. The patient makes a huff sound when exhaling. 4. The patient inhales through the nose with the mouth closed. 5. The patient places one hand on the abdomen and the other on the chest. Answer: 2, 3 Explanation: 1. Coughing twice is part of the controlled coughing technique. 2. For huff coughing, the patient should be instructed to inhale deeply while leaning forward. 3. For huff coughing, the patient should be instructed to exhale sharply with a "huff" sound, to help keep airways open while mobilizing secretions. 4. Inhaling through the nose with the mouth closed is part of the pursed-lip technique. 5. Placing one hand on the abdomen and the other on the chest is part of the diaphragmatic breathing technique. Page Ref: 1356 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

23 ..

25) The nurse is reviewing the results of laboratory and diagnostic tests conducted on a patient experiencing respiratory dysfunction. Which result confirms the nurse's suspicion that the patient has cystic fibrosis? Select all that apply. 1. Patchy infiltrates on chest x-ray 2. Mediastinal shift on chest CT scan 3. Oxygen saturation 82% on room air 4. Chloride concentration of sweat 85 mEq/L 5. Reduced total lung capacity from pulmonary function test Answer: 3, 4, 5 Explanation: 1. Patchy infiltrates on chest x-ray would be associated with pneumonia. 2. Mediastinal shift on chest CT scan is consistent with a tension pneumothorax. 3. In cystic fibrosis, oxygen saturation levels show hypoxemia. 4. Cl− concentration in sweat is analyzed to confirm the diagnosis of cystic fibrosis (CF). In CF, the Cl− concentration is > 70 mEq/L. 5. In cystic fibrosis, pulmonary function studies reveal reduced total lung capacity. Page Ref: 1357 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

24 ..

26) The nurse is caring for a patient experiencing atelectasis of the right lower lung lobe. What intervention should the nurse include in this patient's plan of care? Select all that apply. 1. Positioning on the left side 2. Applying oxygen as prescribed 3. Encouraging increased oral fluids 4. Coaching to deep-breathe and cough 5. Administering antibiotics as prescribed Answer: 1, 3, 4 Explanation: 1. Nursing care to prevent and treat atelectasis is directed toward airway clearance. The patient with atelectasis should be positioned on the unaffected side to promote gravity drainage of the affected segment. 2. Oxygen is not typically prescribed in the treatment of atelectasis. 3. Nursing care to prevent and treat atelectasis is directed toward airway clearance. Unless contraindicated, fluid intake should be encouraged to help liquefy secretions. 4. Nursing care to prevent and treat atelectasis is directed toward airway clearance. Coughing and deep breathing should be encouraged. 5. Antibiotics are not indicated in the treatment of atelectasis. Page Ref: 1361 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

25 ..

27) A chest CT scan confirms that a patient has bronchiectasis. On which problem should the nurse focus when determining the care this patient will need? Select all that apply. 1. Airway clearance 2. Changes in fluid balance 3. Ineffective breathing pattern 4. Inability to provide self-care 5. Insufficient nutritional intake Answer: 1, 3, 4, 5 Explanation: 1. Nursing care of the patient with bronchiectasis is similar to that for patients with other obstructive lung diseases. Airway clearance is a primary problem. 2. Fluid balance is not a potential problem for the patient with bronchiectasis. 3. Nursing care of the patient with bronchiectasis is similar to that for patients with other obstructive lung diseases. Ineffective breathing pattern is a primary problem. 4. Nursing care of the patient with bronchiectasis is similar to that for patients with other obstructive lung diseases. Problems include inability to provide self-care. 5. Nursing care of the patient with bronchiectasis is similar to that for patients with other obstructive lung diseases. Problems include impaired nutrition. Page Ref: 1361 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.1 Describe the pathophysiology and manifestations of reactive airway disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

26 ..

28) A patient is diagnosed with subacute hypersensitivity pneumonitis. What should the nurse expect to assess in this patient? Select all that apply. 1. Weight loss 2. Chronic cough 3. Chills and fever 4. Loss of appetite 5. Shortness of breath Answer: 1, 2, 4, 5 Explanation: 1. The subacute syndrome of hypersensitivity pneumonitis is characterized by weight loss. 2. The subacute syndrome of hypersensitivity pneumonitis is characterized by an insidious onset of chronic cough. 3. Chills and fever are associated with acute hypersensitivity pneumonitis. 4. The subacute syndrome of hypersensitivity pneumonitis is characterized by anorexia. 5. The subacute syndrome of hypersensitivity pneumonitis is characterized by progressive dyspnea. Page Ref: 1362 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.2 Describe the pathophysiology and manifestations of interstitial lung disease, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.

27 ..

29) After an assessment the nurse is concerned that a patient is experiencing cor pulmonale associated with right-heart failure. What finding led the nurse to make this clinical decision? Select all that apply. 1. Ankle edema 2. Ruddy cheeks 3. Nasal drainage 4. Cyanotic nail beds 5. Distended neck veins Answer: 1, 2, 4, 5 Explanation: 1. The manifestations of cor pulmonale are those of the underlying pulmonary disorder and right-sided heart failure. With right-sided heart failure, peripheral edema is seen. 2. The manifestations of cor pulmonale are those of the underlying pulmonary disorder and right-sided heart failure. With right-sided heart failure, the skin is ruddy because of increased numbers of RBCs. 3. Nasal drainage is not a manifestation of cor pulmonale associated with right-heart failure. 4. The manifestations of cor pulmonale are those of the underlying pulmonary disorder and right-sided heart failure. With right-sided heart failure, skin is cyanotic because of hypoxemia. 5. The manifestations of cor pulmonale are those of the underlying pulmonary disorder and right-sided heart failure. With right-sided heart failure, distended neck veins are seen. Page Ref: 1370 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.3 Describe the pathophysiology and manifestations of pulmonary vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with gas exchange disorders.

28 ..

30) The nurse assists in the extubation of a patient recovering from injuries caused by a motor vehicle crash. Which observation indicates that the patient is able to independently maintain an airway? Select all that apply. 1. The patient is coughing. 2. The patient has a hoarse voice. 3. The patient has inspiratory stridor. 4. The patient's oxygen saturation is 75%. 5. The patient swallows small sips of water. Answer: 1, 2, 5 Explanation: 1. When the patient is able to maintain effective respirations and ventilatory support is no longer required, the endotracheal tube is removed (extubation). The cough reflex must be intact to prevent aspiration. 2. A hoarse voice is common after extubation. 3. Inspiratory stridor indicates laryngeal edema, which may necessitate reintubation. 4. An oxygen saturation of 75% indicates that the patient is not receiving adequate oxygen. Reintubation may be necessary. 5. The swallow reflex must be intact to prevent aspiration. Page Ref: 1374 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

29 ..

31) A patient being mechanically ventilated is diagnosed with barotrauma. Which assessment finding would lead the nurse to determine that the patient is experiencing subcutaneous emphysema? Select all that apply. 1. Blood-tinged sputum 2. Swollen neck and face 3. Reduced breath sounds 4. Sudden reduction of heart sounds 5. Crackling sound upon palpation of the skin of the upper chest Answer: 2, 5 Explanation: 1. Blood-tinged sputum is not a manifestation of subcutaneous emphysema. 2. Subcutaneous emphysema, or air in the subcutaneous tissue, causes tissue swelling of the neck and face. 3. Subcutaneous emphysema does not affect breath sounds. 4. Subcutaneous emphysema does not affect heart sounds. 5. With subcutaneous emphysema, "crackling" or air-bubble-popping sensation is felt on palpation. Page Ref: 1377 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with gas exchange disorders.

30 ..

32) The nurse is caring for a patient intubated for acute respiratory distress syndrome (ARDS). Which medication should the nurse expect to be prescribed for this patient? Select all that apply. 1. Surfactant 2. Antibiotics 3. Nitrous oxide 4. Anticoagulants 5. Cardiac glycosides Answer: 1, 3 Explanation: 1. Although there is no definitive drug therapy for ARDS, a number of medications may be used. Surfactant therapy may be prescribed. Surfactant reduces the surface tension within the alveoli, helps maintain open alveoli, reduces the work of breathing, improves compliance and gas exchange, and prevents atelectasis. 2. Antibiotics are not indicated in the treatment of ARDS. 3. Although there is no definitive drug therapy for ARDS, a number of medications may be used. Inhaled nitric oxide reduces intrapulmonary shunting and improves oxygenation by dilating blood vessels in better-ventilated areas of the lungs. 4. Anticoagulants are not indicated in the treatment of ARDS. 5. Cardiac glycosides are not indicated in the treatment of ARDS. Page Ref: 1385 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

31 ..

33) A patient who is intubated is having difficulty being weaned from the ventilator. What action should the nurse take to successfully wean this patient? Select all that apply. 1. Weaning in the morning 2. Placing in high-Fowler's position 3. Limiting activities during weaning 4. Coaching on coughing during weaning 5. Administering a sedative before weaning Answer: 1, 2, 3 Explanation: 1. Interventions to facilitate the weaning process include beginning weaning procedures in the morning, when the patient is well rested and alert; weaning may be discontinued overnight to provide rest. The work of breathing increases during the weaning process; adequate rest is important. 2. Interventions to facilitate the weaning process include placing the patient in Fowler's or highFowler's position to facilitate lung expansion and reduce the work of breathing. 3. Interventions to facilitate the weaning process include limiting procedures and activities during weaning periods. Reducing energy expenditure and cardiac work facilitates the weaning process. 4. The patient is intubated. Coughing will not be effective or encouraged at this time. 5. Administering drugs that may depress respirations during the weaning process should be avoided, except as ordered at night to facilitate rest when ventilator support is provided. Sedatives or analgesics that depress respirations can impair the weaning process. Page Ref: 1386 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 37.4 Describe the pathophysiology and manifestations of respiratory failure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

32 ..

34) A patient with sarcoidosis is being discharged. Which information should the nurse include when providing teaching to this patient? Select all that apply. 1. Reduce the intake of sodium. 2. Expect occasional painful joints. 3. Increase the intake of potassium. 4. Take corticosteroids as prescribed. 5. Report shortness of breath to the healthcare provider. Answer: 1, 3, 4, 5 Explanation: 1. Sodium intake should be reduced to prevent the development of adverse effects from taking corticosteroids. 2. Painful joints should be reported to the healthcare provider. 3. Potassium intake should be increased to prevent the development of adverse effects from taking corticosteroids. 4. Corticosteroids should be taken as prescribed and not stopped abruptly. 5. Shortness of breath should be reported to the healthcare provider. Page Ref: 1364 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 37.2 Describe the pathophysiology and manifestations of interstitial lung disease, and outline the interprofessional care and nursing care of patients with this disorder. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with gas exchange disorders.

33 ..

35) A patient is suspected of having a pulmonary embolism. Which diagnostic test should the nurse anticipate being prescribed for this patient? Select all that apply. 1. Coagulation studies 2. Plasma D-dimer level 3. Complete blood count 4. Pulmonary angiogram 5. Chest CT with contrast Answer: 2, 4, 5 Explanation: 1. Coagulation studies are used to monitor the response to therapy and not diagnose the health problem. 2. Plasma D-dimer levels are highly specific to the presence of a thrombus. D-dimer is a fragment of fibrin formed during lysis of a blood clot; elevated blood levels indicate thrombus formation and lysis. 3. A complete blood count is not used to diagnose a pulmonary embolism. 4. Pulmonary angiography is the definitive test for pulmonary embolism when other, less invasive tests are inconclusive. It is possible to detect very small emboli with angiography. A contrast medium injected into the pulmonary arteries illustrates the pulmonary vascular system on x-ray. 5. Chest CT with contrast is the principal test used to diagnose pulmonary embolism. Chest CT effectively shows large, central PE; newer-generation scanners can also detect peripheral emboli. Page Ref: 1365-1366 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 37.3 Describe the pathophysiology and manifestations of pulmonary vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with gas exchange disorders.

34 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 38 Assessing the Musculoskeletal System 1) A patient recovering from a total hip replacement develops a fever and redness at the surgical site. What should the nurse consider first when assessing this patient? 1. Development of osteomyelitis 2. Subacute osteoporosis 3. Pathological fracture 4. Undiagnosed osteitis deformans Answer: 1 Explanation: 1. Osteomyelitis is an infection of a bone. Since the patient had a total hip replacement, the joint or bone may be infected. 2. Subacute osteoporosis is not a clinical disorder. 3. This patient is not demonstrating signs of a pathological fracture. 4. Osteitis deformans is a chronic disorder that causes irregular bone breakdown and bone weakness. Page Ref: 1401 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

1 ..

2) The nurse is reviewing assigned patients who are scheduled for an MRI. Which patient should the nurse identify as being able to safely undergo an MRI diagnostic test? 1. Patient with a pacemaker for three years 2. Patient with shrapnel from a military assault 3. Patient with an open abdominal wound 4. Patient with external hardware following a fracture repair Answer: 3 Explanation: 1. The nurse must screen patients prior to the examination for metallic implants such as a pacemaker. 2. The nurse must screen patients prior to the examination for metallic implants such as shrapnel. 3. The presence of an open abdominal wound (presumably packed and bandaged) would not cause concern for injury. 4. The nurse must screen patients prior to the examination for metallic implants. Page Ref: 1406 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

2 ..

3) The nurse is assessing an older patient's musculoskeletal status. What should the nurse consider as a normal finding for this patient? Select all that apply. 1. Decreased bone mass and minerals 2. Increased calcium reabsorption 3. Atrophied muscle fibers 4. Elongated vertebrae 5. Decreased range of motion Answer: 1, 3, 5 Explanation: 1. With aging, decreased bone mass and minerals contribute to bones that are thinner and weaker. 2. With aging, decreased calcium absorption contributes to bones that are thinner and weaker. 3. Muscle fibers atrophy with aging, leading to loss of muscle mass, strength, and agility. 4. The vertebrae shorten and height decreases with aging. 5. Range of motion declines with aging as cartilage on bone surfaces in joints deteriorates, making movement more painful. Page Ref: 1407 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.3 Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans. MNL Learning Outcome: 2. Recognize normal findings of the musculoskeletal system collected during assessment and health promotion activities to support the health of this body system.

3 ..

4) A health-conscious young adult female asks the nurse what diagnostic test might help predict the likelihood for developing osteoporosis. Which diagnostic test should the nurse explain? 1. Arthroscopy 2. Electromyogram (EMG) 3. Somatosensory evoked potential (SSEP) 4. Dual energy x-ray absorptiometry (DEXA) Answer: 4 Explanation: 1. Arthroscopy is an endoscopic examination of a joint. 2. The electromyogram measures electrical activity of skeletal muscles at rest and during contraction. 3. The SSEP measures nerve conduction. 4. The DEXA can calculate the size and thickness of bone. Page Ref: 1405 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

4 ..

5) The nurse is documenting data collected during assessments. For which patient should the nurse include "unable to assess" for the Phalen's test? 1. Patient with a long leg cast 2. Patient with an above-the-elbow amputation 3. Patient wearing compression stockings 4. Patient with osteoarthritis of the hips Answer: 2 Explanation: 1. The presence of a leg cast would not deter the nurse from completing the examination. 2. Phalen's test involves holding the wrists in acute flexion against one another for 60 seconds, which isn't possible following upper extremity amputation. Numbness and burning in the fingers could indicate carpal tunnel syndrome. 3. The presence of a compression stocking would not deter the nurse from completing the examination. 4. The presence of hip pain would not deter the nurse from completing the examination. Page Ref: 1403 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

5 ..

6) The nurse is instructing a patient about preparations needed for an electromyogram. Which patient statement indicates that further teaching is required? 1. "I will not smoke any cigarettes up to three hours before the test." 2. "It will be all right to have a glass of water before the test." 3. "I can take my Flexaril before having my test so that my back won't hurt." 4. "I can take my lisinopril the night before my test for my blood pressure." Answer: 3 Explanation: 1. The patient is showing his understanding of the instructions for the test when he states that he will not smoke before the test. 2. It is acceptable to have water before the test as long as there is no intake of fluid with caffeine prior to testing. 3. The patient should not take medications such as muscle relaxants, anticholinergics, or cholinergics prior to testing since the purpose of the test is to measure the electrical activity of skeletal muscles at rest and during contraction. The muscle relaxant Flexaril will alter the results of the function of the skeletal muscles. 4. The patient may take his lisinopril for his blood pressure the night before the test. Page Ref: 1406 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

6 ..

7) In which order should the nurse assess a patient complaining of pain in both knees? Place the four techniques in order of priority. Choice 1. Measurement of muscle mass Choice 2. Range of motion Choice 3. Inspection Choice 4. Palpation Answer: 3, 4, 1, 2 Explanation: The techniques used to assess the musculoskeletal system are inspection, palpation, and measurement of muscle mass and range of motion (ROM). The patient may stand, sit, or lie down, and the sequence of the examination should be such that the patient does not have frequent position changes. Page Ref: 1399-1400 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

7 ..

8) An older patient asks why body height has decreased an inch over the last year. How should the nurse respond to the patient? 1. "Everybody gets shorter as they get older." 2. "There is no need to worry; you only lost 1 inch since last year. You probably won't lose much more than that." 3. "There can be several causes for the loss of height, but as we age, bone mass decreases and the spinal column shortens." 4. "There could be something wrong, so you should discuss it with your physician." Answer: 3 Explanation: 1. Telling the patient that everyone gets shorter as they get older is a nontherapeutic answer to the concern that the patient has and does not address the concern. 2. This answer dismisses the patient's concern and predicts a height loss that may not be accurate. 3. With aging, the spinal column shortens and height decreases. 4. This answer also dismisses the patient's concern and does not give the nurse the opportunity to educate the patient. Page Ref: 1407 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 38.3 Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans. MNL Learning Outcome: 2. Recognize normal findings of the musculoskeletal system collected during assessment and health promotion activities to support the health of this body system.

8 ..

9) An older female patient has an exaggerated curvature of the thoracic spine when bending at the waist. With which alteration does the nurse recognize this finding to be consistent? 1. Kyphosis, which is a common curvature in older patients 2. Kyphosis, which the patient will have to have surgically corrected 3. Scoliosis, which is a normal curvature in the elderly 4. Lordosis, which is common in elderly patients Answer: 1 Explanation: 1. Kyphosis is common in older adult patients. 2. Surgical correction of kyphosis is not a treatment method. 3. Scoliosis is not a normal curvature in the elderly population. 4. Lordosis is an increased lumbar curve and not a normal curvature in the elderly population. Page Ref: 1407 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.3 Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans. MNL Learning Outcome: 2. Recognize normal findings of the musculoskeletal system collected during assessment and health promotion activities to support the health of this body system.

9 ..

10) The nurse is reviewing data collected during the assessment of an older female. What should the nurse identify as being a normal age-related change? Select all that apply. 1. Height decreased 0.5 inch in 2 years 2. Complains of frequent cramping of lower extremities 3. 1 cm nodule palpated in right foot 4. Decreased range of motion in right and left hips 5. Lateral curvature of the spine Answer: 1, 2, 4 Explanation: 1. The height decrease is a geriatric consideration due to the shortening of the spinal column and the decrease in bone mass. 2. Muscle cramping can occur as the muscle fibers atrophy and the fibrous tissue replaces muscle tissue. 3. A nodule that is palpated in the foot is not a change that is common in the geriatric population and should be examined further. 4. Decrease in range of motion is a common finding. 5. Lateral curvature of the spine or scoliosis is not a common geriatric finding and may have several causes. Page Ref: 1407 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.3 Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans. MNL Learning Outcome: 2. Recognize normal findings of the musculoskeletal system collected during assessment and health promotion activities to support the health of this body system.

10 ..

11) While conducting range of motion with an older patient, the patient begins to cry and states, "My knee hurts when you do that!" Which intervention should be implemented at this time? Select all that apply. 1. Continue with the assessment. 2. Stop ROM immediately in that extremity. 3. Massage the knee for 20 minutes. 4. Call the healthcare provider. 5. Have the patient complete the assessment alone. Answer: 2, 4 Explanation: 1. ROM should be performed without causing the patient discomfort. 2. Knee pain may be referred pain from a hip fracture or other hip injury as well as alteration in the structure of the knee. The action should be stopped. 3. Massaging the knee may cause further pain and discomfort to the patient and has no therapeutic benefit at this time. 4. Knee pain may be referred pain from a hip fracture or other hip injury as well as alteration in the structure of the knee. The healthcare provider may order diagnostic tests in order to evaluate the source of the pain. 5. Do not cause further injury by continuing with the assessment. Page Ref: 1403, 1407 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.3 Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

11 ..

12) The nurse is planning to determine whether a patient has fluid in the knee. What should the nurse use to make this assessment? Select all that apply. 1. Ballottement 2. Bulge sign 3. Phalen's test 4. Thomas test 5. McMurray test Answer: 1, 2 Explanation: 1. To assess for larger amounts of fluid in the knee, the nurse should conduct the ballottement test, which is done by applying downward pressure on the knee with one hand while pushing the patella backward against the femur with the other hand. There should be no movement of the patella. The patella should rest firmly over the femur. Increased fluid will cause a tapping sound as the patella displaces the fluid and hits the femur. 2. Bulge sign indicates increased fluid in the knee joint and is indicated to assess for smaller amounts of fluid on the knee. 3. Phalen's test is an assessment tool that may be indicative of carpal tunnel syndrome. 4. The Thomas test may indicate hip contracture. 5. The McMurray test is used to indicate an injury to a meniscus, a disk of cartilaginous tissue in the knee. Page Ref: 1403, 1404 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

12 ..

13) A patient's recovering from surgery to repair a fractured right femur asks what the diaphysis is. How should the nurse respond? 1. "Short bones like the femur are cuboid, spongy bone that in medical terms are called the diaphysis." 2. "Irregular bones like the femur are plates of compact bone that are also called the diaphysis." 3. "Flat bones like the femur are disc-shaped and, in medical terms, are called the diaphysis." 4. "Long bones like the femur have a mid-portion or shaft that is called the diaphysis." Answer: 4 Explanation: 1. The femur is not a short bone. 2. The femur is not an irregular bone. 3. The femur is not a flat bone. 4. The femur is the long bone in the upper leg that consists of the mid-portion (diaphysis) and two broad ends. Page Ref: 1395 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 38.1 Describe the anatomy, physiology, and functions of the musculoskeletal system, and identify abnormal findings that may indicate impairments of the musculoskeletal system. MNL Learning Outcome: 8.1.1. Explain the pathophysiology of traumatic musculoskeletal injuries.

13 ..

14) A patient is prescribed bed rest for two months. What impact should the nurse expect on the patient's skeletal bones? 1. Not be affected by the bed rest 2. Undergo increased osteoclast activity and bone resorption 3. Increase their osteoblastic activity to promote ossification 4. Be affected positively by the rest and be stronger as a result Answer: 2 Explanation: 1. Bones that are not in use for a prolonged time promote bone resorption or bone loss. 2. Bones that are not in use for a prolonged time promote bone resorption or bone loss. Bones that are inactive undergo increased osteoclast activity and bone resorption. 3. Bones that are in use and are subjected to stress increase their osteoblastic activity to increase ossification. 4. Bones that are in use and subjected to stress will increase their osteoblastic activity and develop bone ossification. Page Ref: 1397 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.1 Describe the anatomy, physiology, and functions of the musculoskeletal system, and identify abnormal findings that may indicate impairments of the musculoskeletal system. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

14 ..

15) A patient is seen in the clinic for chronic low blood calcium. What effect will this have on bone health? 1. Bone resorption will be triggered in order to increase serum calcium levels. 2. Bone production will occur in order to help increase the blood calcium. 3. Bones will not be affected because the calcium is low in the blood. 4. Bones will pull the needed calcium from other body structures. Answer: 1 Explanation: 1. When blood levels of calcium decrease, parathyroid hormone (PTH) is released. PTH then stimulates osteoclast activity and bone resorption so that calcium is released from the bone matrix. As a result, blood levels of calcium rise, and the stimulus for PTH release ends. 2. Bone production does not occur to increase low blood calcium levels. 3. Bones will be affected to address the body's need for calcium. 4. There are no other body structures that have adequate amounts of calcium to increase serum levels. Page Ref: 1397 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.1 Describe the anatomy, physiology, and functions of the musculoskeletal system, and identify abnormal findings that may indicate impairments of the musculoskeletal system. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

15 ..

16) A patient is recovering from surgery to repair a fractured arm. Which type of muscle is needed for this extremity to regain function? 1. Cardiac 2. Smooth 3. Skeletal 4. A combination of skeletal and smooth Answer: 3 Explanation: 1. Cardiac muscle is exclusive to the heart. 2. Smooth muscle is found in organs and is not under voluntary control. 3. Skeletal muscle is the only muscle in the body that allows musculoskeletal function. 4. Smooth muscle is not needed for musculoskeletal function. Page Ref: 1397 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.1 Describe the anatomy, physiology, and functions of the musculoskeletal system, and identify abnormal findings that may indicate impairments of the musculoskeletal system. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

16 ..

17) A patient is scheduled for an electromyelogram (EMG). What should the nurse instruct the patient about this diagnostic test? Select all that apply. 1. Do not smoke for 3 hours before the test. 2. Do not take any medication prior to this test without physician approval. 3. The test measures nerve conduction along pathways. 4. The test measures electrical activity of skeletal muscles at rest. 5. Fluids containing caffeine are permitted prior to the test. Answer: 1, 2, 4 Explanation: 1. When preparing the patient for the testing, instruct the patient to avoid behaviors that may influence the test. This includes no smoking for 3 hours before the test. 2. The physician must have the final determination regarding which medications can be allowed prior to the testing. 3. The electromyelogram (EMG) does not measure nerve conduction along pathways. 4. The electromyelogram (EMG) measures the electrical activity of skeletal muscles at rest. 5. When preparing the patient for the testing, instruct the patient to avoid behaviors that may influence the test. This includes avoiding fluids containing caffeine. Page Ref: 1406 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

17 ..

18) The nurse is preparing to assess a patient's musculoskeletal status. In which order should the nurse perform the techniques of this examination? Place the four techniques in the correct order. Choice 1. Assess joints for swelling, pain, redness, warmth, crepitus, and range of motion (ROM). Choice 2. Inspect and palpate the bones for any obvious deformity or changes in size, shape, or a painful response. Choice 3. Measure the extremities for length and circumference, and compare limbs bilaterally. Choice 4. Assess gait and posture. Answer: 4, 2, 3, 1 Explanation: When performing an assessment of the musculoskeletal system, first review the patient's gait and posture. Inspection is the next technique. Inspect and palpate the bones for any obvious deformity or changes in size or shape. Palpation also will elicit tenderness or pain. Inspect the extremities for symmetry, having equal length and muscle mass. If a difference is noted, measure extremity length and circumference, comparing limbs bilaterally. Inspect and palpate joints for swelling, pain, redness, or warmth. Page Ref: 1400 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

18 ..

19) The nurse is teaching a patient about an endoscopic examination of the interior surfaces of a joint during which surgery and diagnosis can also be accomplished. About which technique is the nurse instructing the patient? 1. Arthrocentesis 2. Arthroscopy 3. Atherogenesis 4. Arthrodesis Answer: 2 Explanation: 1. Arthrocentesis is the clinical procedure of using a syringe to collect synovial fluid from a joint capsule; it is used in the diagnosis of gout, arthritis, and synovial infections. 2. Arthroscopy is the endoscopic examination of the interior surfaces of a joint during which surgery and diagnosis can also be accomplished. 3. Atherogenesis is the formation of subintimal plaques in the lining of arteries. 4. Arthrodesis is the artificial induction of joint ossification between two bones. Page Ref: 1405 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

19 ..

20) The patient is about to have a magnetic resonance imaging (MRI) to diagnose a soft tissue abnormality of the lower leg. About which finding should the nurse immediately notify the healthcare provider? 1. The patient has a concern about what will be found on the MRI. 2. The patient has a pacemaker. 3. The patient has a history of hypertension. 4. The patient did not eat breakfast due to earlier nausea. Answer: 2 Explanation: 1. All tests have the capacity to promote patient concern and anxiety. This is a normal behavior and does not require healthcare provider notification. 2. The patient will be prohibited from having an MRI due to the pacemaker. Metallic implants prevent the test because radio waves and magnetic fields are used. 3. The presence of hypertension will not have an adverse impact on the MRI results. 4. The presence of reduced dietary intake will not have an adverse impact on the MRI results. Page Ref: 1406 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

20 ..

21) A patient needs an x-ray of the arm. What should the nurse do to prepare the patient for this diagnostic test? 1. Initiate a peripheral IV in the opposite arm. 2. Find out the patient's allergies. 3. Do no special preparation. 4. Cleanse the arm with antibacterial cleanser. Answer: 3 Explanation: 1. Routine x-rays do not require the patient to have an IV inserted. 2. Allergies will not impact routine x-ray studies. 3. No special preparation is needed for standard x-rays. 4. Cleaning the extremity is not necessary for the x-ray. Page Ref: 1406 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

21 ..

22) A patient is scheduled for a bone scan. For which health problem should the nurse suspect this test is being used to diagnose? 1. Bone cancer 2. A muscle mass near the bone 3. New onset pain in the area of the bone 4. Normal calcium level Answer: 1 Explanation: 1. Bone scans show increased uptake of the radioisotope in bone cancer. 2. The bone scan would do little to provide a definite analyzing of a muscle mass. 3. New onset bone pain would require other initial evaluation studies. 4. A bone scan is not indicated to diagnose a normal calcium level. Page Ref: 1406 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

22 ..

23) An older female patient is scheduled to have a DEXA examination. What should the nurse consider as most likely the reason the test has been prescribed for this patient? 1. Check for fractures. 2. Check the degree of osteoporosis. 3. Screen for osteomyelitis. 4. Evaluate bone cancer. Answer: 2 Explanation: 1. X-rays would be used to assess for the presence of fractures. 2. The bone density examination (DEXA) evaluates bone mineral density and the degree of osteoporosis. 3. Bone scans would be used in the evaluation of osteomyelitis. 4. Bone scans would be used in the evaluation of potential bone cancer. Page Ref: 1406 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.4 Summarize topics that nurses teach to promote a healthy musculoskeletal system across the lifespan. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

23 ..

24) The nurse is caring for an older patient. What should the nurse realize is an expected agerelated change in this patient's musculoskeletal system? 1. Difficulty with dexterity after age 50 2. Vertebrae lengthening and thinning, which leads to increased bone production 3. Decreased bone mass and calcium absorption, which increase risk for fractures 4. Pain when ambulating due to increased bone mass and minerals Answer: 3 Explanation: 1. Difficulty with dexterity is not necessarily a usual occurrence after age 50. 2. Bone production does not increase with aging. 3. Normal aging is associated with a reduction in bone mass and calcium absorption. 4. Pain with ambulation is not associated with increased bone mass. Page Ref: 1407 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.3 Differentiate considerations for assessing the musculoskeletal systems of older adults and veterans. MNL Learning Outcome: 2. Recognize normal findings of the musculoskeletal system collected during assessment and health promotion activities to support the health of this body system.

24 ..

25) The nurse is caring for a patient with a musculoskeletal disorder. For which reason does the nurse suspect the patient's alkaline phosphatase (ALP) is being assessed? 1. Establish true calcium levels 2. Evaluate the presence of bone diseases 3. Determine phosphorus levels 4. Diagnose muscle trauma Answer: 2 Explanation: 1. Blood tests other than ALP establish calcium levels. 2. Alkaline phosphatase (ALP) levels are assessed in patients who are experiencing musculoskeletal disorders in order to evaluate the presence of bone diseases. 3. Blood tests other than ALP establish phosphorus levels. 4. Blood tests other than ALP diagnose muscle trauma. Page Ref: 1405 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

25 ..

26) A patient is having a creatine kinase (CK) level drawn. For which health problem would the nurse expect this level to be elevated? 1. Juvenile rheumatoid arthritis 2. Gout 3. Muscle disease 4. Bone tumors Answer: 3 Explanation: 1. Juvenile rheumatoid arthritis is a systemic disease process that affects the body's joints and other systems; CK levels will not assist in its diagnosis. 2. Uric acid levels are used to diagnose gout. 3. CK (the isoenzyme CK-MM) is elevated in muscle trauma and muscle disease. 4. The presence of bone tumors would be identified by radiological testing. Page Ref: 1405 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

26 ..

27) A patient has an elevated blood calcium, elevated alkaline phosphatase, elevated phosphorus, normal creatine kinase, and increased uptake of the radioisotope on bone scan. Which health problem should the nurse suspect is occurring with this patient? 1. Bone spurs 2. Rheumatoid arthritis 3. Osteoporosis 4. Bone cancer Answer: 4 Explanation: 1. X-rays would be useful in diagnosis of bone spurs. 2. Rheumatoid factor is used to diagnose rheumatoid arthritis. 3. This condition would not produce the same blood value alterations. 4. The test results are a likely combination in a patient with bone cancer. The blood values described would be anticipated because the bone levels would be reduced in the presence of a malignancy. The other conditions listed would not produce the same blood value alterations. Areas of disease will demonstrate an increase in uptake of radioisotopes on the scans. Page Ref: 1405, 1406 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

27 ..

28) A patient seeks medical attention because of right knee pain and swelling that occurred while playing basketball. What should the nurse expect to be prescribed for this patient? 1. The patient will be sent home with instructions to use ice for one week. 2. The patient will be admitted to the hospital and seen by an orthopedic specialist. 3. The patient will be scheduled to see an orthopedic physician and a tentative appointment for a magnetic resonance imaging (MRI) scan. 4. The patient will be admitted to the hospital and scheduled for exploratory surgery. Answer: 3 Explanation: 1. The possible injury to the knee (likely cartilage injury) will be evaluated by a specialist and a decision will be made regarding the need for the MRI. 2. This injury would not be considered an emergency if alterations in sensation, perfusion, and movement of the leg are present. Since these changes are not noted on assessment, hospitalization or surgery would not be indicated. 3. The possible injury to the knee (likely cartilage injury) will be evaluated by a specialist and a decision will be made regarding the need for the MRI. An MRI would evaluate tears of a ligament or cartilage. 4. This injury would not be considered an emergency if alterations in sensation, perfusion, and movement of the leg are present. Since these changes are not noted on assessment, hospitalization or surgery would not be indicated. Page Ref: 1406 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

28 ..

29) The nurse determines that a patient's gait is normal. What did the nurse assess to make this clinical decision? Select all that apply. 1. The patient does not stumble, run into objects, or fall. 2. The gait is smooth and steady without limping. 3. The gait is slow and deliberate as if the patient is gingerly pulling one side up to meet the other. 4. The gait is jerky and quick, which indicates the patient has excellent motor control. 5. The posture is upright and straight. Answer: 2, 5 Explanation: 1. Slow, jerky, or stumbling movements are abnormalities that warrant further evaluation. 2. Alterations in gait can be difficult to assess. The nurse should watch the patient walk from the front and from behind and look closely to see that gait is smooth and steady. 3. Slow, deliberate movements can indicate pain or another health problem. 4. Slow, jerky, or stumbling movements are abnormalities that warrant further evaluation. 5. The nurse should watch the patient walk from the front and from behind and look closely to see that posture is upright and straight. Page Ref: 1401 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

29 ..

30) A patient is diagnosed with a disease that affects fibrous tissue. In which musculoskeletal area should the nurse expect the patient to experience health problems? Select all that apply. 1. Hips 2. Teeth 3. Shoulders 4. Skull bones 5. Distal tibia and fibula Answer: 2, 4, 5 Explanation: 1. Synovial tissue is located in the hip joint. 2. Fibrous tissue connects bones through collagen fibers. The areas of the patient's body that would be affected include the teeth and sockets. 3. Synovial tissue is located in the shoulder joints. 4. Fibrous tissue connects bones through collagen fibers. The areas of the patient's body that would be affected include the skull sutures. 5. Fibrous tissue connects bones through collagen fibers. The areas of the patient's body that would be affected include the ligament connecting the distal tibia and fibula. Page Ref: 1398 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.1 Describe the anatomy, physiology, and functions of the musculoskeletal system, and identify abnormal findings that may indicate impairments of the musculoskeletal system. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

30 ..

31) The nurse is preparing to assess a patient with myotonic dystrophy. For what health problem should the nurse assess this patient? Select all that apply. 1. Hair loss 2. Cataracts 3. Long extremities 4. Spinal deformities 5. Significant muscle wasting Answer: 1, 2, 5 Explanation: 1. Myotonic dystrophy is an inherited disorder in which the muscles become weak and have a decreased ability to relax. Other manifestations include hair loss. 2. Myotonic dystrophy is an inherited disorder in which the muscles become weak and have a decreased ability to relax. Other manifestations include cataracts. 3. Long extremities are a characteristic of Marfan syndrome. 4. Spinal deformities are seen in Marfan syndrome. 5. Myotonic dystrophy is an inherited disorder in which the muscles become weak, have a decreased ability to relax, and eventually waste away. Page Ref: 1404 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the musculoskeletal system collected during assessment.

31 ..

32) The nurse is completing a health history with a patient. When assessing for a family or genetic history of musculoskeletal disorders, what should the nurse include? Select all that apply. 1. Gout 2. Fibromyalgia 3. Osteoarthritis 4. Lupus erythematosus 5. Ankylosing spondylitis Answer: 1, 3, 4, 5 Explanation: 1. Musculoskeletal diseases believed to have a genetic component include gout. 2. Fibromyalgia is not believed to have a genetic component. 3. Musculoskeletal diseases believed to have a genetic component include osteoarthritis. 4. Musculoskeletal diseases believed to have a genetic component include lupus erythematosus. 5. Musculoskeletal diseases believed to have a genetic component include ankylosing spondylitis. Page Ref: 1404 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

32 ..

33) A patient is experiencing numbness and tingling of the left foot. When assessing this patient's limb, which movements should the nurse use to determine motor function of the patient's left ankle? Select all that apply. 1. 120-degree flexion 2. 50-degree adduction 3. 20-degree dorsiflexion 4. 45-degree plantar flexion 5. 30-degree hyperextension Answer: 3, 4 Explanation: 1. Flexion of 120 degrees is used to assess the function of the knee joint. 2. Adduction of 50 degrees is used to assess function of the shoulder joint. 3. Dorsiflexion is performed by bending the ankle to bring the top of the foot toward the shin. 4. Plantar flexion is the straightening of the ankle to point the toes down. 5. Adduction of 50 degrees is used to assess function of the shoulder joint. Page Ref: 1403 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

33 ..

34) The nurse notes that a patient is prescribed to have a human leukocyte antigen (HLA) test completed. For which health problem should the nurse potentially plan care for this patient? Select all that apply. 1. Osteoporosis 2. Paget disease 3. Rheumatoid arthritis 4. Ankylosing spondylitis 5. Juvenile rheumatoid arthritis Answer: 4, 5 Explanation: 1. Alkaline phosphatase is used to diagnose bone diseases such as osteoporosis. 2. Alkaline phosphatase is used to diagnose bone diseases such as Paget disease. 3. Alkaline phosphatase is used to diagnose bone diseases such as rheumatoid arthritis. 4. The human leukocyte antigen (HLA) test is used to diagnose diseases such as ankylosing spondylitis. 5. The human leukocyte antigen (HLA) test is used to diagnose diseases such as juvenile RA. Page Ref: 1405 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the musculoskeletal system.

34 ..

35) The nurse is assessing a patient with carpal tunnel syndrome. What assessment technique should the nurse use to determine this patient's finger function? Select all that apply. 1. Making a fist 2. Shaking hands 3. Spreading the fingers 4. Straightening the arm 5. Bending the hand forward and backward Answer: 1, 2, 3 Explanation: 1. To assess the function of the fingers, the nurse should ask the patient to make a fist. 2. To assess the function of the fingers, the nurse should ask the patient to shake hands. 3. To assess the function of the fingers, the nurse should ask the patient to spread the fingers. 4. Straightening the arm assesses the triceps muscle. 5. Bending the hand forward and backward assesses the wrist muscles. Page Ref: 1402 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

35 ..

36) The nurse completes a physical assessment on a patient recovering from a stroke. The patient has no muscle function of the left leg and passive range of motion of the left arm. The right leg and arm have full range of motion against full resistance. How should the nurse document the muscle grading of these assessment findings? Select all that apply. 1. 0 left leg 2. 2 left arm 3. 3 left arm 4. 5 right leg 5. 5 right arm Answer: 1, 2, 4, 5 Explanation: 1. A grading of 0 means no muscle function. 2. A grading of 2 means function with passive range of motion. 3. A grading of 3 means full range of motion against gravity. 4. A grading of 5 means full range of motion against full resistance. 5. A grading of 5 means full range of motion against full resistance. Page Ref: 1400 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Management of Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 38.2 Outline the components of the assessment of the musculoskeletal system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the musculoskeletal system.

36 ..

37) The nurse is preparing teaching material for a community fair. What should the nurse include to ensure good bone health? Select all that apply. 1. Avoid obesity 2. Reduce smoking 3. Limit alcohol intake 4. Adequate intake of calcium 5. Engage in weight-bearing exercise Answer: 1, 4, 5 Explanation: 1. Avoiding obesity is important to maintain good bone health in all adults. 2. Smoking is not identified as a factor for bone health. 3. Alcohol is not identified as a factor for bone health. 4. An adequate intake of calcium is essential to ensure maintenance of strong bones throughout life. 5. Weight-bearing exercise is essential to ensure maintenance of strong bones throughout life. Page Ref: 1407 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 38.4 Summarize topics that nurses teach to promote a healthy musculoskeletal system across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the musculoskeletal system collected during assessment and health promotion activities to support the health of this body system.

37 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 39 Nursing Care of Patients with Musculoskeletal Trauma 1) The nurse instructs an adolescent patient on the care of a sprain at home. Which patient statement indicates the need for further instruction? 1. "I should put a heating pad on my leg as soon as I get home." 2. "I should avoid weight bearing on this leg for a couple of days." 3. "I should make sure to keep the ace bandage on my leg." 4. "I should prop this leg up when I'm sitting in a chair." Answer: 1 Explanation: 1. Heat should not be applied to a sprain. 2. The patient should be instructed to rest the extremity for 24-48 hours. 3. The patient should be instructed to apply compression to the injured extremity for 24-48 hours. 4. The patient should be instructed to elevate the extremity, which reduces pain and edema, for 24-48 hours. Page Ref: 1412 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

1 ..

2) A patient with a long leg cast is exhibiting signs of compartment syndrome. What should the nurse prepare to aid in the treatment of the patient? 1. Extra pillows to elevate the casted extremity above the heart 2. Doppler to assess the strength of peripheral pulses 3. Straps to wrap around the bivalved cast 4. Percussion hammer to assess reflexes for damage Answer: 3 Explanation: 1. Elevating the leg above the heart would compromise circulation. 2. A Doppler could be used to assess pulses but this is not a therapeutic treatment for compartment syndrome. 3. Compartment syndrome occurs when excess pressure in a limited space constricts the structures within a compartment, reducing circulation to muscles and nerves. Treatment can include removing the cast entirely or bivalving it (splitting it apart with a cast cutter) and securing the two sides with straps. 4. A percussion hammer is used to check reflexes, but this is not a therapeutic treatment for compartment syndrome. Page Ref: 1431 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

2 ..

3) A patient is placed in Buck's traction after a hip fracture. What should be included in this patient's plan of care? 1. Providing pin site care every shift as prescribed 2. Placing an abduction pillow between the legs for alignment 3. Having another person hold the weights when pulling the patient up in bed 4. Turning the patient to the unaffected side every 2 hours Answer: 3 Explanation: 1. Buck's traction is skin traction; no skeletal pins are used. 2. An abduction pillow is used postoperatively. 3. Buck's traction is used preoperatively to control muscle spasms, immobilize a fractured hip, and maintain alignment of an extremity. Often, patients will "scoot" down toward the end of the bed, and the weights are resting on the floor. To avoid injury and added pain, one person holds the weights while the others use a lift sheet to reposition the patient. 4. A patient cannot be turned with this type of therapy. Page Ref: 1428 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

3 ..

4) The nurse is planning care for a patient recovering from an above-the-knee amputation. Which position should the nurse include in this patient's plan of care? 1. Sims' position as tolerated 2. Prone for 1 hour, several times a day 3. High Fowler's position 4. Sitting in a chair while awake Answer: 2 Explanation: 1. Sims' position would likely be uncomfortable for the patient. 2. A complication following above-the-knee amputation is developing a contracture of the joint above the amputation. Lying prone prevents abnormal flexion and fixation of the extremity. 3. High Fowler's position can lead to hip contracture. 4. Prolonged sitting can lead to hip contracture. Page Ref: 1443 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

4 ..

5) The nurse is concerned that a patient is at risk for developing carpal tunnel syndrome. Which occupation would increase this patient's risk? Select all that apply. 1. Farmer 2. Police officer 3. Barber 4. Computer technician 5. Carpet installer Answer: 3, 4, 5 Explanation: 1. Normal activities would not place a farmer at risk. 2. Normal activities would not place a police officer at risk. 3. Carpal tunnel syndrome is diagnosed by the patient's history and physical examination. The history may reveal an occupation that involves the use of the hands. 4. Carpal tunnel syndrome is diagnosed by the patient's history and physical examination. The history may reveal an occupation that involves computer work. 5. Carpal tunnel syndrome is diagnosed by the patient's history and physical examination. The history may reveal an occupation that involves mechanical work with the hands. Page Ref: 1416 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Lifestyle Choices Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal trauma.

5 ..

6) A patient is diagnosed with an open compound fracture and is scheduled for immediate surgery. On which problem should the nurse focus during the patient's immediate postoperative period? 1. Difficulty with mobility 2. Anxiety related to the surgical procedure 3. Potential for infection 4. Possibility of falling Answer: 3 Explanation: 1. The patient will have difficulty with mobility; however, this is not the priority during the immediate postoperative period. 2. The surgery has been completed. The risk of anxiety about the surgery should be resolved. 3. The patient with an open, compound fracture has multiple bone breaks penetrating through the skin, and must be assessed and cared for vigilantly for signs of infection. 4. The patient may have problems ambulating and be at risk for falling; however, this is not the priority during the immediate postoperative period. Page Ref: 1418 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

6 ..

7) The nurse is caring for a patient with a long leg cast. What should the nurse include when assessing this patient for indications of compromised circulation? Select all that apply. 1. Swelling of the toes 2. Drainage on the cast 3. Increased temperature 4. Foul odor 5. A tight cast Answer: 1, 5 Explanation: 1. Constriction of circulation reduces venous return and increases pressure within the vessels. Fluid then shifts into the interstitial space, causing edema. 2. Drainage would indicate potential infection. 3. Increased temperature would indicate potential infection. 4. Foul odor would indicate potential infection. 5. Edema can cause the cast to become tight. A tight-fitting cast can lead to compartment syndrome. Page Ref: 1431 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

7 ..

8) A patient is diagnosed with a humeral fracture. What should the nurse identify as a priority treatment goal for the patient? 1. Immediate surgical correction 2. Immobilizing the fractured bone in normal anatomic position 3. Applying ice and compression to the injured arm 4. Applying elastic bandage wrap and elevating the arm Answer: 2 Explanation: 1. Immediate surgical correction is not the correct intervention for this diagnosis. 2. The priority is to immobilize the bone so that the fracture will heal in its correct anatomic position. This will allow unimpaired range of motion and prevent deformities or misalignment of the arm. 3. Applying ice and compression to the injured arm is not the top priority intervention. 4. Applying an ace wrap and elevating the injured arm is not the top priority intervention. Page Ref: 1422 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

8 ..

9) A patient with facial and chest injuries from a motor vehicle accident has rhonchi in the upper airways. For which problem should the nurse plan care? 1. Inability to clear the airway 2. Problem with swallowing 3. Changes in oral mucous membrane integrity 4. Potential for additional injury Answer: 1 Explanation: 1. The patient has facial fractures with subsequent edema that will compromise the airway. The airway must be maintained by helping the patient clear secretions from the oropharynx. 2. Although problems swallowing may be a possibility, they are not a priority at this time. 3. There is no evidence that the patient has changes in oral mucous membrane integrity. 4. There is no evidence that the patient is at risk for additional injuries. Page Ref: 1422 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

9 ..

10) An older patient lives at home alone. Which assessment data would indicate modifiable risk factors for a hip fracture? Select all that apply. 1. Complaints of lower extremity weakness 2. Problems with balance 3. Medications: atenolol 50 mg daily, lisinopril 10 mg daily, Xanax 0.25 mg daily, Seroquel 50 mg daily 4. Report of sleeping with two pillows 5. Complaints of nonproductive dry cough Answer: 1, 2, 3 Explanation: 1. Modifiable risk factors for hip fracture include lower body weakness. 2. Modifiable risk factors for hip fracture include problems with walking and balance. 3. Modifiable risk factors for hip fracture include taking four or more medications or any psychoactive medications. 4. Sleeping with two pillows is not considered a modifiable risk factor. 5. A nonproductive cough is not considered a modifiable risk factor. Page Ref: 1423 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal trauma.

10 ..

11) A patient is diagnosed with a sprained right ankle. Which treatment should the nurse instruct the patient for the sprain? 1. Applying of a long leg cast 2. Pain medication 3. Heat, rest, compression, and elevation 4. Protection, rest, ice, compression, and elevation Answer: 4 Explanation: 1. Sprains are not treated with casts. 2. Anti-inflammatory medications are best for sprains. 3. Heat is contraindicated for treatment of sprains, as it may increase swelling and increase pain. 4. The interventions in PRICE therapy allow the injured muscle, ligament, or tendon to be protected; heal (rest); cause vasoconstriction and reduce pain (ice); decrease edema formation and pain (compression); and promote venous return to decrease edema and pain (elevation). Page Ref: 1412 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

11 ..

12) A patient is recovering from endoscopic carpal tunnel surgery. Which statement indicates that the surgery has been effective? 1. "I only feel numbness when I've been on the computer for more than 15 minutes." 2. "I guess in a couple of months the numbness will go away." 3. "I will always have some tingling in my fingers after I've been on the computer." 4. "I'm not feeling tingling or numbness in my thumb or index finger any longer." Answer: 4 Explanation: 1. This statement indicates the surgery has not been effective. 2. This statement indicates the surgery has not been effective. 3. This statement indicates the surgery has not been effective. 4. Carpal tunnel syndrome occurs as a result of inflammation and swelling of the synovial lining of the tendon sheath, which causes irritation of the median nerve. After the release of the carpal tunnel, the patient should have no further problems with numbness, tingling, or pain. Page Ref: 1416-1417 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

12 ..

13) A patient is diagnosed with epicondylitis. Which treatment may be indicated for this patient? Select all that apply. 1. Ibuprofen 600 mg twice daily 2. Morphine sulfate 4 mg IV 3. Arm splint to be used while awake 4. Ice followed by heat 5. Surgical repair Answer: 1, 3, 4 Explanation: 1. Epicondylitis is the inflammation of the tendon at its point of origin in the humerus and is also referred to as "tennis elbow" or "golfer's elbow." Initial treatment is conservative and includes administration of nonsteroidal anti-inflammatory drugs such as ibuprofen. 2. Morphine sulfate is not the drug of choice for a patient with epicondylitis. 3. The arm may be immobilized by applying an arm splint. 4. Ice may be applied, followed by heat, every 4 hours. 5. Surgical repair is not indicated this soon before other less drastic measures are employed. Page Ref: 1416 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

13 ..

14) A patient diagnosed with bursitis asks, "Why do you keep asking what my pain level is? Don't you believe me?" How should the nurse respond? 1. "It is important to know your pain level so that we can provide you with the best medication." 2. "If you don't want the medication, you don't have to take it." 3. "I can't give you the medication unless I know what your pain level is." 4. "I don't understand why you are concerned about my questions. Would you clarify?" Answer: 1 Explanation: 1. The nurse should explain the importance of assessing for pain so that appropriate medication can be provided. Asking the patient to rate the pain on a scale of 0-10 before and after any intervention is important to assess the effectiveness of the chosen pain relief strategy. 2. The patient did not indicate he does not want medication. 3. This response does not address the question of the nurse believing the patient. 4. The patient has not indicated concern but is merely questioning. Page Ref: 1417 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

14 ..

15) A patient is diagnosed with an oblique fracture of the left femur. In which order should the nurse explain the steps of healing? Place in the correct order the steps of the process. Choice 1. Bony callus formation Choice 2. Fibrocartilaginous callus formation Choice 3. Hematoma formation Choice 4. Remodeling Answer: 3, 2, 1, 4 Explanation: Choice 1. The third stage of fracture healing, bony callus formation, begins 3 to 4 weeks after the injury and continues for 2 to 3 months. Osteoblasts continue to form collagen fibers and bone matrix, which are gradually mineralized with calcium and mineral salts. Choice 2. Within 48 hours, fibroblasts and new capillaries growing into the fracture form granulation tissue that gradually replaces the hematoma. Phagocytes remove cell debris. Osteoblasts migrate to the fracture site, where they build a web of collagen fibers from both sides of the fractured bone. Chondroblasts lay down patches of cartilage as a base for bone growth. This fibrocartilaginous callus connects bone fragments, splinting the fracture and maintaining bone alignment. Choice 3. When a bone fractures, bleeding and tissue damage at the site of the fracture initiate an inflammatory response. A hematoma forms between the fractured bone ends and around the bone surfaces. Choice 4. During the remodeling phase, excess callus is removed and new bone is laid down along the fracture line. The fracture site calcifies and the bone reunites. Page Ref: 1418 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal trauma.

15 ..

16) An older patient with a history of diabetes is experiencing poor healing of a fractured ankle. Which factor should the nurse consider that contributes to this patient's delay in bone healing? Select all that apply. 1. Immobilization 2. Advanced age 3. Diabetes 4. Moderate activity level prior to injury 5. Presence of foreign body at the fracture site Answer: 2, 3, 5 Explanation: 1. Immobilization would be a positive factor. 2. Advanced age would have a negative effect on bone healing. 3. A systemic disease such as diabetes would have a negative effect on bone healing. 4. A moderate activity level before the fracture would be a positive factor. 5. The presence of a foreign body such as glass or dirt would be a negative factor in bone healing. Page Ref: 1422 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal trauma.

16 ..

17) After sustaining a fracture, a patient was treated by applying ice and a cast. After several weeks, the cast is removed and the patient is able to ambulate without difficulty. Which positive local factor influenced this patient's bone healing? Select all that apply. 1. Immobilization 2. Timely correction of displacement 3. Application of ice 4. Delay in correction of displacement 5. Malnutrition Answer: 1, 2, 3 Explanation: 1. The limb was immobilized. This is a positive local factor that influenced bone healing. 2. The limb was casted. This is a positive local factor that influenced bone healing. 3. The patient was immediately treated with ice. This is a positive local factor that influenced bone healing. 4. There was no delay in treatment and bone healing occurred within the expected time frame. 5. There is no indication the patient was malnourished. Page Ref: 1422 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

17 ..

18) Nonunion of a fractured tibia is seen in a patient after 8 weeks in a long leg cast. Which intervention may be necessary to encourage bone healing? 1. Removing the old cast and reapplying another 2. Placing the patient in Buck's traction 3. Surgical intervention with open reduction and internal fixation 4. Bone debridement Answer: 3 Explanation: 1. Removing the cast and applying a new one would not help a patient with a nonunion fracture. 2. Buck's traction is not indicated. 3. With nonunion, the patient will have persistent pain and movement at the fracture site. The site will need to be realigned and held in place with plates and screws to maintain the alignment. 4. There is no evidence that the bone needs to be debrided. Page Ref: 1437 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

18 ..

19) A patient diagnosed with a fractured left femur complains of chest pain, shortness of breath, and a rash on the chest. What complication should the nurse suspect? 1. Fat embolism syndrome 2. Deep vein thrombosis 3. Compartment syndrome 4. Disseminated intravascular coagulation (DIC) Answer: 1 Explanation: 1. Long bone fractures and other major trauma are the primary risk factors for fat embolism syndrome. When the bone is fractured, pressure within the bone marrow rises and exceeds capillary pressure; as a result, fat globules leave the bone marrow and enter the bloodstream. The fat globules lodge in the pulmonary vascular bed or peripheral circulation. Manifestations usually develop within a few hours to a week after injury due to the occlusion of blood supply and the presence of fatty acids. 2. The symptoms do not indicate deep vein thrombosis. 3. The symptoms do not indicate compartment syndrome. 4. The symptoms do not indicate DIC. Page Ref: 1436 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

19 ..

20) The nurse suspects that a patient is experiencing fat embolism syndrome (FES). Which assessment data supports the nurse's clinical decision? Select all that apply. 1. Pulse oximetry 88% 2. Petechiae observed on the chest and upper arms 3. Complaints of shortness of breath 4. Respiratory rate 32 breaths/min 5. Skin warm and dry Answer: 1, 2, 3, 4 Explanation: 1. Pulmonary circulation may be disrupted, and free fatty acids damage the alveolar-capillary membrane. Pulmonary edema, impaired surfactant production, and atelectasis can result in significant respiratory distress syndrome. 2. Petechiae may result from microvascular clotting or the accompanying thrombocytopenia. 3. Respiratory manifestations of dyspnea are often the first indicator of FES. 4. Respiratory manifestations of tachypnea are often the first indicators of FES. 5. This is a normal finding. Page Ref: 1437 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

20 ..

21) A patient recovering from a fractured hip is at risk for developing deep vein thrombosis (DVT). Which treatment would be indicated for the patient at this time? 1. Heparin 2. Prevention 3. Vena cava filter 4. Massaging the affected extremity Answer: 2 Explanation: 1. Heparin may be used to treat DVT but not to prevent it. 2. The best treatment for DVT is prevention. Early mobilization of the fracture and early ambulation of the patient are imperative. Frequent assessment of the injured extremity may lead to early recognition of DVT and prevent the formation of pulmonary embolus. Antiembolism stockings and sequential compression devices will increase venous return and prevent stasis of blood. 3. This is not indicated. 4. Massaging may increase the risk for DVT. Page Ref: 1437 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

21 ..

22) A patient with an open fracture of the left femur that punctured the skin waited 2 hours before getting to the hospital. What would be the priority problem to address when caring for this patient? 1. Insufficient nutrition 2. High potential for infection 3. Low body temperature 4. Fear and anxiety Answer: 2 Explanation: 1. There is no indication of malnutrition. 2. The open bone fracture has been exposed to contaminants. The delay in treatment prolongs the patient's exposure to bacteria. This patient is at risk for infection that can delay healing and possibly result in osteomyelitis and ultimately a loss of the limb. 3. There is no indication the patient is hypothermic. 4. The patient might be fearful and anxious, but this is not a priority at this time. Page Ref: 1437 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

22 ..

23) The nurse is explaining to a patient the procedure to alleviate pressure on a casted extremity. How should the nurse explain the procedure? 1. "This procedure is called bivalving. The doctor will use a cast saw to split the cast down both sides to relieve pressure on your leg." 2. "This procedure is called an external fixation and will help the bone heal." 3. "This procedure is called an open reduction with internal fixation to help the bone fuse together." 4. "This procedure will help heal your leg faster so that the cast can come off sooner." Answer: 1 Explanation: 1. Bivalving is the process of splitting the cast down both sides to alleviate pressure on or allow visualization of the extremity. 2. This procedure is not external fixation. 3. This procedure is not open reduction with internal fixation. 4. The goal of this procedure is not specifically to promote faster healing. Page Ref: 1431 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

23 ..

24) The nurse has identified that a patient recovering from an above-the-knee amputation has a problem with pain control. Which nursing intervention would be beneficial for this patient? Select all that apply. 1. Administering analgesics before pain reaches a higher level 2. Splinting and supporting the injured area 3. Elevating the stump on three pillows 4. Encouraging deep breathing and relaxation exercises 5. Repositioning the patient every 8 hours Answer: 1, 2, 4 Explanation: 1. Analgesics alleviate pain by stimulating opiate receptor sites. Giving pain medication when the pain is rated at a lower level allows for more effective pain management. 2. Splinting prevents additional injury by immobilizing the stump and reducing edema while molding the stump for a good prosthetic fit. 3. Elevating the stump can increase the risk for hip contractures. 4. Deep breathing and relaxation will increase the effectiveness of analgesics and modify the pain experience. 5. The patient should be repositioned every 2 hours to prevent muscle cramping and prolonged pressure on any area. Page Ref: 1442 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

24 ..

25) A patient is recovering from a below-the-knee amputation. For which complication should the nurse assess this patient? Select all that apply. 1. Diabetes mellitus 2. Phantom pain 3. Infection 4. Chronic stump pain 5. Contractures Answer: 2, 3, 4, 5 Explanation: 1. Diabetes mellitus is not a complication of a below-the-knee amputation. 2. Phantom limb pain more frequently affects people who had pain in the amputated limb prior to its removal than those who did not. 3. A patient who experiences a traumatic amputation has a greater risk of infection than the person who has a planned amputation. However, even planned amputations carry a risk of infection. 4. Chronic stump pain is the result of neuroma formation. 5. A contracture is an abnormal flexion and fixation of a joint caused by muscle atrophy and shortening. Contracture of the joint above the amputation is a common complication. Page Ref: 1446 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

25 ..

26) The nurse is teaching older adults about lowering the risk for musculoskeletal trauma. Which strategy should the nurse include? 1. Avoid falls at home by not using throw rugs. 2. Avoid injury in motor vehicle accidents by not driving. 3. Avoid fire by not cooking in the kitchen when alone. 4. Avoid injury by not using assistive devices at home. Answer: 1 Explanation: 1. The nurse should teach ways to make the home safe, including the elimination of throw rugs. 2. Advising adults to avoid driving is not realistic. 3. Advising adults to avoid cooking is not realistic. 4. Assistive devices are intended to promote independence and should be used by patients who need them. Page Ref: 1438 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

26 ..

27) The nurse is concerned that patients on an orthopedic care area are at risk for compartment syndrome. In which circumstance should the nurse assess for manifestations of compartment syndrome? Select all that apply. 1. Fasciotomy 2. Cast applied to a limb 3. Crush injury to a limb 4. Fat embolism 5. Total hip replacement surgery Answer: 2, 3 Explanation: 1. Fasciotomy is a treatment that can be used in the management of compartment syndrome. 2. External compression of a limb by a cast that constricts the limb can lead to compartment syndrome. 3. Acute compartment syndrome may result from hemorrhage and edema within the compartment after a fracture, crush injury, or surgery. 4. Fat embolism is a complication associated with long bone fractures or crushing injuries. 5. Compartment syndrome does not typically occur after hip replacement surgery. Page Ref: 1436 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

27 ..

28) The nurse is caring for a patient receiving care on the orthopedic unit. Which assessment finding indicates that the patient is developing complex regional pain syndrome? 1. Complains of persistent pain, swelling, and decreased motion 2. Bone has not healed within the expected time period 3. Complains of leg swelling, pain, tenderness, and cramping 4. Complains of numbness beyond a cast, and toes are pale, with delayed capillary refill Answer: 1 Explanation: 1. Complex regional pain syndrome (CRPS) is characterized by intense pain in the affected limb, as well as sensory, autonomic, motor, skin, and bone changes of the extremity. 2. The failure of a fracture to heal within the usual time period is characteristic of nonunion or delayed union. 3. Leg swelling, pain, tenderness, and cramping are symptoms of deep vein thrombosis. 4. Numbness beyond a cast and toes that are pale with delayed capillary refill are symptoms of possible compartment syndrome. Page Ref: 1437 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

28 ..

29) Following the application of a cast to a patient's right lower leg, the nurse is monitoring for complications. Which assessment data leads the nurse to be concerned about a serious complication? 1. The toes on the right foot are pink and warm, and sensation is intact. 2. The patient complains of numbness in the right foot and toes. 3. The patient reports itching under the cast. 4. The patient complains of general discomfort in the lower-right leg. Answer: 2 Explanation: 1. The exposed extremities should be pink and warm, with sensation. 2. Numbness should be reported right away. It may indicate pressure on nerves or blood vessels related to a tight cast, which can lead to compartment syndrome. 3. Itching is anticipated for the patient who recently had a cast applied. 4. Generalized discomfort is anticipated for the patient who recently had a cast applied. Page Ref: 1436 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

29 ..

30) A patient is scheduled to have skeletal traction. What should the nurse recognize about this type of traction? 1. Weighted skin traction will be applied. 2. A surgical pin will be inserted into a bone and the traction will be applied to the pin. 3. A cast will be applied to the area and a traction device will be connected to the cast. 4. Manual traction will be applied. Answer: 2 Explanation: 1. Skin traction is used in short-term therapies and does not require the insertion of mechanical hardware. 2. Skeletal traction requires the insertion of a pin directly into the bone. This insertion is performed under sterile conditions in the surgical environment. Skeletal traction is used when more weight or longer-term immobilization is desired to maintain proper alignment. 3. A cast is not applied in skeletal traction. 4. Manual traction is not part of skeletal traction. Page Ref: 1427-1428 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

30 ..

31) The nurse is caring for a patient with an external fixator device. What care should the nurse provide to this patient? 1. Cleansing pin sites per orders to reduce the chance of infection 2. Adjusting the tension on the pins whenever the patient experiences pain 3. Explaining that bathing in a tub can be resumed after 3 days 4. Encouraging the patient to keep the limb with the external fixator very still Answer: 1 Explanation: 1. The pins require care to reduce the risk of infection. 2. Adjusting the device is outside the scope of nursing; this is a physician's responsibility. 3. Bathing (soaking in water) in a tub is not permitted due to the chance of infection through pin sites. 4. An external fixator is meant to increase the patient's independence while maintaining immobilization. Page Ref: 1429 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

31 ..

32) A patient whose recovery from a fracture has been very slow is prescribed a treatment that will increase the migration of osteoblasts and osteoclasts to the fracture site. For which treatment should the nurse instruct this patient? 1. Open reduction and manipulation 2. Open visualization and debridement 3. Electrical bone stimulation 4. Fracture assimilation Answer: 3 Explanation: 1. Surgical intervention will not increase the migration of osteoblasts and osteoclasts. 2. Surgical intervention will not increase the migration of osteoblasts and osteoclasts. 3. Electrical bone stimulation, in which an electrical current is applied at the fracture site, increases the migration of osteoblasts and osteoclasts to the site. 4. Surgical intervention will not increase the migration of osteoblasts and osteoclasts. Page Ref: 1428-1429 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

32 ..

33) A patient with facial fractures has a pulse of 108 bpm, respiratory rate of 24 breaths/min, and obvious deformities to the right side of the face. What should the nurse identify as the priority of care for this patient? 1. Frequently assessing the blood pressure for signs of shock and initiating IV fluids 2. Monitoring the elevated respiratory rate and maintaining the airway 3. Monitoring the elevated pulse rate and looking for signs of pallor 4. Frequently assessing for facial pain and administering pain medication p.r.n. Answer: 2 Explanation: 1. Although IV fluids may be initiated, the patient's assessment does not reflect a significant risk for shock. 2. With facial fractures, the potential risk for airway compromise must be considered. The nurse helps the patient clear secretions from the oropharynx and reports elevated respiratory rate (tachypnea) to the physician. 3. The injuries will cause bruising and discoloration, not pallor. 4. While the patient will require ongoing pain assessment and management, this is not the most important nursing action. Page Ref: 1422 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

33 ..

34) A patient is prescribed PRICE therapy. How should the nurse describe the components of this therapy? 1. Protection, rest, ice, compression, and elevation 2. Protection, rest, ice, CT scan, and elimination of pain 3. Protection, rest, immobilization, CT scan, and elimination of pain 4. Protection, rest, immobilization, compression, and elevation Answer: 1 Explanation: 1. PRICE is an acronym for protection, rest, ice, compression, and elevation. 2. CT scan and elimination of pain are not part of the treatment plan. 3. Immobilization, CT scan, and elimination of pain are not part of the treatment plan. 4. Immobilization is not part of the treatment plan. Page Ref: 1412 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

34 ..

35) A patient recovering from an amputation refuses to look at the stump or participate in care. For what problem should the nurse plan interventions to help this patient? 1. Infection 2. Insufficient nutrition 3. Problems with body image 4. Risk for chronic pain Answer: 3 Explanation: 1. The patient's reluctance to look at the wound does not indicate a risk for infection. 2. There is no indication that the patient has insufficient nutrition. 3. Although amputation is a reconstructive surgery, the patient's body image will be disturbed. The patient's reluctance to look at the stump or participate in care supports this problem identification. 4. There is no evidence that the patient will experience chronic pain. Page Ref: 1443 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal trauma.

35 ..

36) The nurse needs to reposition a patient with a fractured leg. Which action should the nurse take when moving this patient? 1. Making sure the extremity is supported distal to the fracture 2. Disconnecting the weights from the balanced traction setup 3. Supporting the extremity above and below the fracture 4. Supporting the leg directly under the fracture Answer: 3 Explanation: 1. Supporting the limb distally may cause pain or spasms. 2. If traction were in use, weights would not be removed. 3. Support above and below the fracture site helps prevent displacement of bony fragments and reduces the risk of further nerve damage. 4. Supporting the leg directly under the fraction can cause pain and spasms. Page Ref: 1430 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

36 ..

37) A patient is diagnosed with a rotator cuff tear. Which intervention should the nurse expect to be prescribed for this patient? Select all that apply. 1. Joint rest 2. NSAIDs 3. Moist heat 4. Physical therapy 5. Immediate surgery Answer: 1, 2, 3, 4 Explanation: 1. Treatment for rotator cuff injuries is usually conservative and includes joint rest. 2. Treatment for rotator cuff injuries is usually conservative and includes NSAIDs. 3. Treatment for rotator cuff injuries is usually conservative and includes moist heat. 4. Treatment for rotator cuff injuries is usually conservative and includes physical therapy for persistent problems. 5. Some patients require surgery to repair a torn rotator cuff; however, surgery is not immediately performed. Page Ref: 1414 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 39.1 Describe the pathophysiology and manifestations of traumatic injuries of the muscles, ligaments, and tendons, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal trauma.

37 ..

38) The healthcare provider is pleased that an adolescent's broken arm has healed within 4 weeks. What factor in the patient's health history facilitated the healing of this fracture? Select all that apply. 1. The patient is 17 years old. 2. There are no active disease processes in the health history. 3. The patient waited 4 hours to get the fracture treated. 4. The patient bicycles and plays tennis nearly every day. 5. The patient drinks four 8-ounce glasses of milk a day. Answer: 1, 2, 4, 5 Explanation: 1. Positive systemic factors that affect wound healing include younger age. 2. Positive systemic factors that affect wound healing include the absence of infection or diseases. 3. A delay in the correction of the displacement is a local factor that would negatively impact the healing of the fracture. 4. Positive systemic factors that affect wound healing include a moderate activity level prior to injury. 5. Positive systemic factors that affect wound healing include adequate amounts of calcium. Page Ref: 1422 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

38 ..

39) The nurse is evaluating the effectiveness of instruction provided to a patient with a newly applied arm cast. Which statement indicates that additional teaching is required? Select all that apply. 1. "I can wrap the cast in plastic wrap to protect it." 2. "I can use a blow dryer to make the cast dry faster." 3. "I will call the doctor if the arm starts to hurt more." 4. "I can use a sling to distribute the weight of the cast." 5. "I can use a coat hanger to scratch itchy skin under the cast." Answer: 2, 5 Explanation: 1. The cast can be wrapped in plastic wrap to protect it. 2. The cast dries from the inside out; a blow dryer should not be used to speed drying. 3. The healthcare provider should be notified if pain increases. 4. A sling can be used to distribute the weight of an arm cast evenly around the neck. 5. Nothing should be inserted under the cast. A blow dryer on the cool setting can be used to relieve itching. Page Ref: 1428 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

39 ..

40) The nurse is concerned that a patient with a below-the-knee amputation is at risk for delayed healing. What information from the patient's medical history led the nurse to make this clinical decision? Select all that apply. 1. Body mass index 15 2. History of hypokalemia 3. Smokes 2 ppd of cigarettes 4. Takes vitamin supplements 5. Treated for right heart failure Answer: 1, 2, 3, 5 Explanation: 1. Healing after an amputation is delayed if the patient's diet lacks the proper nutrients to meet the body's increased metabolic demands during healing. 2. Electrolyte imbalances can contribute to delayed healing processes. 3. Smoking compromises healing by causing vasoconstriction and reduced blood flow to the stump. 4. Vitamin supplements would help with wound healing. 5. Decreased cardiac output reduces blood flow and delays healing. Page Ref: 1440 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal trauma.

40 ..

41) The nurse is providing discharge instructions to a patient recovering from an above-theknee amputation. What should the nurse include in this teaching? Select all that apply. 1. Techniques for wrapping the stump 2. Installation of grab bars in the bathroom 3. Type and frequency of stump exercises 4. The importance of resting with the stump elevated on pillows 5. Resuming activities of daily living as soon as possible Answer: 1, 2, 3, 5 Explanation: 1. The nurse should teach the patient to wrap the stump appropriately in preparation for fitting the prosthesis. 2. The nurse should discuss household modifications to promote independence, such as grab bars in the bathroom. 3. The nurse should teach the patient how to perform stump exercises to maintain joint mobility and muscle tone in the affected limb. 4. Elevating the stump on pillows can cause contractures, which will interfere with the ability to effectively use a prosthesis. 5. The patient should be encouraged to resume physical activities as soon as possible. This improves the patient's health, well-being, and self-esteem. Page Ref: 1445 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 39.2 Describe the pathophysiology and manifestations of traumatic injuries of bones, and outline the interprofessional care and nursing care of patients with these injuries. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal trauma.

41 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 40 Nursing Care of Patients with Musculoskeletal Disorders 1) A 30-year-old female patient diagnosed with early onset of osteoporosis asks how she could be at risk for this disease, since she is so active. Which response by the nurse is most correct? 1. "You might have placed underlying stress on your skeleton from your frequent exercise." 2. "You are at an age when your estrogen levels have begun to decline drastically, thus increasing your risk for the development of osteoporosis." 3. "Do your bones feel weak or painful?" 4. "Your dietary practices might be partially responsible." Answer: 4 Explanation: 1. Exercise is beneficial in the prevention of osteoporosis. It does not increase the likelihood of osteoporosis. 2. At 30 years of age, this is unlikely. 3. The patient is seeking information. She is not requiring an assessment at this time. 4. There is an increasing incidence of osteoporosis in female athletes as a result of intense dieting. Page Ref: 1451 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

1 ..

2) A patient with osteoporosis taking calcitonin is experiencing nausea and vomiting. What should the nurse do about the patient's complaint? 1. Alternate nares when administering the medication. 2. Hold the next dose of calcitonin and notify the physician. 3. Monitor and record the frequency and amount of emesis. 4. Increase the amount of vitamin D in the diet. Answer: 3 Explanation: 1. Changing the route will not affect the adverse effects of this medication. 2. Holding the dose is not indicated, and the physician does not require immediate notification. 3. Calcitonin is associated with nausea and vomiting. These manifestations will subside. The nurse will need to record the event. 4. Although vitamin D intake should be increased in the diet when calcitonin is prescribed, it does not address the question. Page Ref: 1453 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

2 ..

3) A patient is prescribed etidronate (Didronel). Which intervention would be appropriate when administering the medication to the patient? Select all that apply. 1. Administer the medication in the morning with water. 2. Administer the medication with milk. 3. Administer the medication after meals. 4. Assess fluoride levels annually. 5. Avoid intake for 30 minutes after use. Answer: 1, 5 Explanation: 1. The medication is best administered with water 30 minutes before a meal. 2. Milk products should be avoided. 3. The medication should be taken on an empty stomach. 4. There is no reason to evaluate fluoride levels with this medication. 5. Intake must be avoided for 30 minutes after administration. Page Ref: 1453 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

3 ..

4) An older patient with osteoporosis has a history of falls and dementia. What intervention will best aid in the prevention of injuries? 1. Using wrist restraints 2. Using furniture as obstacles to keep the patient in the bed 3. Keeping the bed in a low position 4. Keeping a nightlight on in the room Answer: 3 Explanation: 1. The use of restraints could increase the incidence of injury. 2. Using the furniture as an obstacle could cause injury if the patient is able to get up. 3. Keeping the bed in a low position will reduce the incidence of injury should the patient attempt to get up. 4. A nightlight is useful but is not the best means to prevent injury. Page Ref: 1455 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

4 ..

5) A patient diagnosed with gout is concerned that the small "lumps" on the ear and big toe will become lodged in the blood, resulting in a blood clot. What explanation by the nurse is the most accurate response to this patient? 1. "Clots will not develop if you take your anti-gout medicine." 2. "Unfortunately, this is a common complication associated with gout." 3. "You will need to talk with the physician during your next visit." 4. "These 'lumps' do not cause clot development." Answer: 4 Explanation: 1. Medications prescribed to manage gout will reduce the amount of uric acid production or assist with its metabolism. 2. The small "lumps" will not cause a clot. 3. Advising the patient to wait until a future visit to discuss the concern is not appropriate, as the patient is seeking information at the present time. 4. The deposits are known as tophi. They result from uric acid crystal buildup. They occur most often in locations with lower body temperature readings. They will not cause a clot. Page Ref: 1461 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

5 ..

6) A patient with gout is experiencing foot pain. Which intervention will aid in promoting comfort in this patient? 1. Wrap the extremity in an elastic bandage. 2. Encourage liberal fluid intake. 3. Encourage active range-of-motion exercises to promote flexibility. 4. Elevate the extremity and use a foot a cradle. Answer: 4 Explanation: 1. Wrapping the extremity could increase the pain being experienced. 2. Fluid intake will not reduce the foot pain. 3. Range-of-motion exercises could increase the pain being experienced. 4. The pain in the affected extremity will be lessened with elevation. Elevation will reduce inflammation. A foot cradle keeps bed linens from applying pressure on the affected joint. Page Ref: 1463 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

6 ..

7) A patient with osteoarthritis reports achieving pain relief when using an over-the-counter ointment on the affected areas. When reviewing safe administration practices, which principle should the nurse include in the teaching? 1. Apply heat to the affected area after applying ointment. 2. Alternate heat and cold after ointment application. 3. Limit the use of ointment to 3-4 times per day. 4. Initial skin irritation is common and will subside within a few weeks of initiating treatment. Answer: 3 Explanation: 1. Heat use and these preparations should not be combined. 2. Heat use and these preparations should not be combined; cold applications do not promote pain relief. 3. Over-the-counter preparations should be used only 3-4 times per day. 4. If skin irritation is noted, the medication should be discontinued. Page Ref: 1467 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

7 ..

8) Prior to signing informed consent for a total hip replacement, the patient asks the nurse if she should be concerned about complications. How should the nurse respond? 1. "Complications are rare with this type of surgery." 2. "Do you know someone who had complications after this type of surgery?" 3. 'Your surgeon has a low complication rate." 4. "What complications did your surgeon mention in the explanation of your surgery?" Answer: 4 Explanation: 1. Complications can result from any surgery. 2. One person may not have the same postoperative course as someone else. 3. Many variables in addition to the surgeon complication rate influence the occurrence of complications. 4. The surgeon should include risks and benefits when the surgery is discussed with the patient. After assessing the patient's understanding of the procedure, the nurse should provide further explanations and clarification as needed. Potential problems associated with a total hip replacement include venous thromboembolic events, dislocation within the prosthesis, loosening of joint components from surrounding bone, and infection. Page Ref: 1468 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

8 ..

9) A patient with a history of osteoarthritis reports discomfort unrelieved by the prescribed medications. Which nonpharmacological intervention might assist the patient in managing the discomfort? Select all that apply. 1. Suggest the use of ice to the painful joints. 2. Encourage rest of the painful joints. 3. Discuss the use of relaxation techniques. 4. Encourage distraction techniques. 5. Advise the patient to avoid water-based exercises. Answer: 1, 2, 3, 4 Explanation: 1. Ice may decrease the patient's discomfort. 2. Rest is a nonpharmacological method to reduce pain associated with osteoarthritis. 3. Relaxation techniques are nonpharmacological methods to reduce pain associated with osteoarthritis. 4. Distraction is a nonpharmacological method to reduce pain associated with osteoarthritis. 5. Water-based exercises are recommended for the patient with osteoarthritis. Page Ref: 1467-1471 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

9 ..

10) The nurse is reviewing modifiable and nonmodifiable risk factors of osteoporosis with a patient. What should the nurse include as a modifiable risk factor? Select all that apply. 1. Calcium deficiency 2. High-protein diet 3. Female 4. Decrease in estrogen levels 5. Diabetes mellitus Answer: 1, 2, 4 Explanation: 1. Calcium deficiency is an important modifiable risk factor that contributes to osteoporosis. Calcium and vitamin D supplements and a diet including foods high in calcium and vitamin D will help correct the deficiency. 2. A high-protein diet can cause acidosis, which can contribute to osteoporosis since calcium is withdrawn from the kidney as the kidneys attempt to buffer the excess acid. 3. Being female is an unmodifiable risk factor. 4. Decreasing levels of the hormone estrogen are a modifiable risk factor for osteoporosis. 5. Diabetes mellitus is not a modifiable risk factor, although it may be controlled. Page Ref: 1451 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

10 ..

11) The nurse is reviewing the health histories for a group of assigned patients. Which patient should the nurse identify as being at the greatest risk for the development of osteoporosis? Select all that apply. 1. A Caucasian female 2. A postmenopausal female 3. A large-boned African American female 4. A patient taking corticosteroid therapy 5. A 32-year-old male Answer: 1, 2, 4 Explanation: 1. European Americans are at a higher risk for osteoporosis. 2. Low estrogen levels associated with being postmenopause is a modifiable risk factor for the development of osteoporosis. 3. African Americans have a lower risk for osteoporosis because of denser bone mass. 4. Anyone who takes a glucocorticoid medication for more than 3 months is at risk for glucocorticoid-induced osteoporosis. 5. A 32-year-old male has a low risk of developing osteoporosis. Page Ref: 1450-1451 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

11 ..

12) A patient is diagnosed with Paget disease. What should the nurse expect to assess in this patient? Select all that apply. 1. Pain and aching in the spine at night that is aggravated by pressure 2. Flushing of the skin over the spine 3. Previous pathologic fractures to the vertebra 4. Elevated phosphorus levels 5. Scoliosis Answer: 1, 2, 3 Explanation: 1. Most patients that are affected by Paget disease are symptom free for years and the disease may be seen on an incidental x-ray. The pain is described as a mild to moderate deep ache that is aggravated by pressure and weight bearing. 2. Because of the increase in blood flow to pagetic bone, flushing and warmth of the overlying skin may be apparent. 3. Pathologic fractures from the loss of bone structure are a complication of Paget disease. 4. Hypercalcemia, not hyperphosphatemia, is found during laboratory analyzing. 5. Lordosis, not scoliosis, is observed in those with Paget disease. Page Ref: 1458 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

12 ..

13) A patient with gout is prescribed colchicine. For which laboratory value should the nurse question administering this medication to the patient? 1. WBC 20,000 2. Uric acid level 7.8 3. BUN 68 4. Hgb 14.2 Answer: 3 Explanation: 1. A WBC of 20,000 is within normal limits. 2. A uric acid level of 7.8 is within normal limits. 3. The patient should be evaluated for renal failure on the basis of his elevated BUN levels. Colchicine is contraindicated in renal disease. 4. Hgb of 14.2 is within normal limits. Page Ref: 1462 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal disorders.

13 ..

14) A patient with osteoporosis is prescribed alendronate (Fosamax). What should the nurse include when instructing the patient about this medication? Select all that apply. 1. Report new or worsening heartburn, and difficult or painful swallowing. 2. Take the medication with orange juice one hour after food. 3. Do not lie down for 30 minutes after taking medication. 4. Take vitamin C supplements as instructed for bone mineralization. 5. This medication has a gradual response and continues for months after the drug is stopped. Answer: 1, 3, 5 Explanation: 1. New or worsening heartburn, and difficult or painful swallowing are adverse reactions to the medication. 2. Alendronate should be administered with water 30 minutes before food or other medications. 3. Lying down within 30 minutes of ingestion of the medication may precipitate adverse gastrointestinal reactions. 4. Vitamin D supplements should be used as well as calcium and not vitamin C. 5. This medication has a gradual response and continues for months after the drug is stopped. Page Ref: 1453 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

14 ..

15) The nurse is instructing a patient about foods high in calcium. Which food choice that the patient selects indicates teaching has been effective? Select all that apply. 1. Chicken 2. Collard greens 3. Bananas 4. Sardines 5. Whole milk Answer: 2, 4, 5 Explanation: 1. Chicken is not high in calcium. 2. Other food sources of calcium include dark green, leafy vegetables such as collard greens. 3. Bananas are not a source of calcium. 4. Other food sources of calcium include sardines. 5. Milk and milk products are the best sources of calcium. Page Ref: 1454 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

15 ..

16) A patient diagnosed with systemic lupus erythematosus has laboratory values indicative of an exacerbation. Which value should the nurse report to the healthcare provider? Select all that apply. 1. Positive antinuclear antibody 2. ESR 120 mm/hr 3. Trace blood in urine 4. Hemoglobin 14.2 mg/dL 5. Sodium 138 mg/dL Answer: 1, 2, 3 Explanation: 1. Antinuclear antibody (ANA) testing is positive in more than 98% of patients with SLE. 2. ESR is typically elevated, occasionally to >100 mm/hr. 3. Urinalysis shows hematuria during exacerbations of the disease. 4. The hemoglobin level is within normal range. 5. The sodium level is within normal range. Page Ref: 1490 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

16 ..

17) A patient diagnosed with systemic lupus erythematosus is experiencing a facial rash. What should the nurse instruct the patient regarding skin care? Select all that apply. 1. Avoid being out of doors during hours of greatest sun intensity. 2. Use sunscreen with an SPF of 15 or higher. 3. Apply hydrocortisone cream 1% to the rash 4‒6 times/day. 4. Reapply sunscreen after swimming, exercising, or bathing. 5. Wear a wide-brimmed hat when outside. Answer: 1, 2, 4, 5 Explanation: 1. The patient should avoid being out of doors during peak sun hours. 2. The patient should always use sunscreen with SPF of 15 or higher. 3. Do not apply hydrocortisone cream regularly to the face. It can cause skin atrophy and will not provide rash relief. 4. Always reapply sunscreen after perspiring or being exposed to water. 5. Wear loose clothing with long sleeves and wide-brimmed hat when out of doors. Page Ref: 1491 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

17 ..

18) The nurse is providing discharge instructions to a patient recovering from a total hip replacement. What should the nurse include in these instructions? Select all that apply. 1. Use and weight bearing of affected limb 2. Not to do exercises if experiencing discomfort 3. Possible complications such as infection or dislocation 4. Continuing pain medications for only two days after discharge 5. Full recovery in up to six months Answer: 1, 3, 5 Explanation: 1. Patient education should focus on the continued progression of exercise and ambulation. 2. There will be some degree of discomfort when exercising the affected limb, but this can be controlled with mild analgesics. 3. Patient should be instructed to report increasing pain, redness, swelling, fever or deformity of hip. 4. Postoperative pain medication will be necessary for longer than two days. Without proper pain control, the patient may not progress with exercise and ambulation. 5. Recovery from total hip replacement is 80% complete in four weeks and 100% complete in six months. Page Ref: 1469-1470 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

18 ..

19) A patient recovering from a total hip replacement has vital signs assessed by unlicensed assistive personnel. Which vital sign value should cause the most concern for the nurse? 1. Blood pressure 110/76 mmHg 2. Heart rate 82 bpm 3. Respiratory rate 18 breaths/min 4. Temperature 102°F Answer: 4 Explanation: 1. Blood pressure of 110/76 mmHg is within normal limits. 2. Heart rate of 82 bmp is within normal limits. 3. Respiratory rate of 18 breaths/min is within normal limits. 4. The elevated temperature may indicate an infectious process, such as a surgical site infection, and would need rapid intervention. Page Ref: 1470 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with musculoskeletal disorders.

19 ..

20) The patient who weighs 70 kg is to receive 750 mg of abatacept (Orencia) by IV infusion for the treatment of rheumatoid arthritis. When reconstituted, the medication has dosage strength of 25 mg/mL. How many milliliters of the medication should be prepared for this dosage? Record your answer rounding to the nearest whole number. Answer: 30 mL Explanation: Abatacept (Orencia), like other biologic DMARDs, is given by IV infusion. The usual dosage is 500 to 1000 mg per IV infusion every two weeks for two doses, then every month. To calculate the patient's dose the nurse can use the equation Dosage Required/Dosage Available × mL or 750 mg/25 mg × 1 mL = 750/25 × 1 mL = 30 mL. Page Ref: 1481 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

20 ..

21) A patient diagnosed with Paget disease has been prescribed pamidronate 90 mg over 3 days. Medication instructions state to mix 30 mg of the drug in 500 mL NS and administer over 4 hours. This administration should be repeated for 3 days for a total of 90 mg of drug. At what IV rate, in mL/hr, should the nurse run this infusion? Record your answer rounding to the nearest whole number. Answer: 125 mL/hr Explanation: Pamidronate (Aredia) is among the primary treatments for severe Paget disease for inhibiting bone reabsorption. Pamidronate is given as an intravenous infusion for three successive days. The nurse would determine the rate to deliver the medication by dividing the total amount of fluid by 4 hours or 500 mL/4 hr = 125 mL/hr. Page Ref: 1453, 1458 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

21 ..

22) The nurse is providing teaching about topical medications for a group of patients who have been diagnosed with osteoarthritis. Which medication should the nurse review as being a topical preparation? 1. Ketoprofen 2. Naproxen 3. Capsaicin 4. Celecoxib Answer: 3 Explanation: 1. Ketoprofen is an oral medication. 2. Naproxen is an oral medication. 3. Capsaicin is a topical preparation proven to relieve pain in patients with osteoarthritis without the adverse systemic effects of oral medications. 4. Celecoxib is an oral medication. Page Ref: 1467 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

22 ..

23) The nurse is reviewing the x-ray report for a patient experiencing spinal and major joint discomfort. Which finding should indicate to the nurse that the patient will be treated for Paget disease? Select all that apply. 1. Linear fractures 2. Radiolucent bands 3. Increased bone thickness 4. Mosaic pattern of bone matrix 5. Punched out appearance of bone Answer: 1, 3, 4, 5 Explanation: 1. Radiologic changes with Paget disease include linear fractures. 2. Radiolucent bands known as Looser's zones are radiologic changes associated with osteomalacia. 3. Radiologic changes with Paget disease include increase in bone thickness. 4. Radiologic changes with Paget disease include mosaic pattern of bone matrix. 5. Radiologic changes with Paget disease include punched-out appearance of bone. Page Ref: 1452 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

23 ..

24) An older female patient is prescribed a calcium supplements every day. What should the nurse instruct the patient about this supplement? Select all that apply. 1. Take 500 mg of calcium with lunch. 2. Take 500 mg of calcium with breakfast. 3. Take 400 mg of calcium with breakfast, lunch, and dinner. 4. Take 600 mg of calcium with breakfast and 600 mg at bedtime. 5. Take the full dose of 1200 mg of calcium in the morning on an empty stomach. Answer: 1, 2, 3 Explanation: 1. The nurse should recommend that the prescribed dose of calcium be limited to no more than 500 mg at a time because the amount absorbed declines at higher doses. This means that the maximum dose for any meal should be 500 mg of calcium. This would be appropriate for lunch. 2. The nurse should recommend that the prescribed dose of calcium be limited to no more than 500 mg at a time because the amount absorbed declines at higher doses. This means that the maximum dose for any meal should be 500 mg of calcium. This would be appropriate for breakfast. 3. The nurse should recommend that the prescribed dose of calcium be limited to no more than 500 mg at a time because the amount absorbed declines at higher doses. Recommending 400 mg of calcium with breakfast, lunch, and dinner would be appropriate. 4. Calcium should be taken with food, so recommending a dose at bedtime is not appropriate. 5. Calcium should be taken with food, so recommending the complete dose on an empty stomach is not appropriate. Page Ref: 1454 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

24 ..

25) A patient with Paget disease asks why a dose of zoledronic acid (Reclast) is being provided before having total hip replacement surgery. How should the nurse respond to this patient? Select all that apply. 1. "It is to treat your osteoporosis." 2. "It prevents a postoperative infection." 3. "It speeds healing of the surgical wound." 4. "It slows the progression of the Paget disease." 5. "It reduces the amount of bleeding from surgery." Answer: 4, 5 Explanation: 1. A bisphosphonate before surgery in the patient with Paget disease is not provided to treat osteoporosis. 2. Antibiotics are used to treat infection. 3. The bisphosphonate will not speed the healing of the surgical wound. 4. Excessive operative bleeding is a risk in Paget disease due to increased vascularity of affected bone. Pretreatment with a potent bisphosphonate reduces disease activity prior to surgery. 5. Excessive operative bleeding is a risk in Paget disease due to increased vascularity of affected bone. Pretreatment with a potent bisphosphonate decreases the risk of excessive operative blood loss. Page Ref: 1458 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

25 ..

26) The nurse is assessing a patient being treated for osteomalacia. Which findings does the nurse recognize as an indication that the patient is experiencing hypervitaminosis D? Select all that apply. 1. Bruising 2. Anorexia 3. Constipation 4. Muscle weakness 5. Frequent urination Answer: 2, 3, 4, 5 Explanation: 1. Bruising is not a manifestation of hypervitaminosis D. 2. Manifestations of hypervitaminosis D include anorexia. 3. Manifestations of hypervitaminosis D include constipation. 4. Manifestations of hypervitaminosis D include muscle weakness. 5. Manifestations of hypervitaminosis D include frequent urination. Page Ref: 1465 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.1 Describe the pathophysiology and manifestations of metabolic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

26 ..

27) The parents of a 15-year-old patient are informed that diagnostic tests are needed to determine if musculoskeletal changes are being caused by muscular dystrophy. For which type of muscular dystrophy should the nurse expect these tests to be prescribed? Select all that apply. 1. Becker 2. Myotonic 3. Duchenne 4. Limb-girdle 5. Facioscapulohumeral Answer: 2, 4, 5 Explanation: 1. Becker muscular dystrophy affects males. 2. Myotonic muscular dystrophy affects males and females at any age. 3. Duchenne muscular dystrophy affects males. 4. Limb-girdle muscular dystrophy affects males and females between the ages of 15 and 40. 5. Facioscapulohumeral muscular dystrophy affects males and females between the ages of 10 and 20. Page Ref: 1474 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.2 Describe the pathophysiology and manifestations of degenerative musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

27 ..

28) During an assessment, the nurse suspects that a patient is experiencing manifestations of rheumatoid arthritis. What finding did the nurse observe to make this clinical decision? Select all that apply. 1. Weight loss 2. Hot red swollen joints 3. Hip and knee affected 4. Cool and bony hard joints 5. Pain and stiffness in the morning Answer: 1, 2, 5 Explanation: 1. Weight loss is a systemic manifestation of rheumatoid arthritis. 2. Hot red swollen joints are manifestations of rheumatoid arthritis. 3. Hip and knees are affected in osteoarthritis. 4. Cool and bony hard joints are manifestations of osteoarthritis. 5. Pain and stiffness in the morning are manifestations of rheumatoid arthritis. Page Ref: 1476 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

28 ..

29) A 36-year-old patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse include when teaching the patient about this medication? Select all that apply. 1. Avoid alcohol. 2. Avoid exposure to sunlight. 3. Use effective contraception. 4. Expect the skin to turn orange. 5. Have routine eye examinations. Answer: 1, 2, 3 Explanation: 1. The nurse should instruct the patient to avoid alcohol while taking methotrexate. 2. The nurse should instruct the patient to avoid exposure to sunlight or ultraviolet light while taking methotrexate. 3. The nurse should instruct the patient to practice effective contraception while taking methotrexate. 4. Yellow-orange skin is associated with sulfasalazine (Azulfidine). 5. Routine ophthalmologic examinations are needed for hydroxychloroquine (Plaquenil) because of the risk of developing retinopathy. Page Ref: 1481 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

29 ..

30) A patient is diagnosed with Lyme disease. Which medication should the nurse expect to be prescribed for managing the manifestations of this health problem? Select all that apply. 1. Aspirin 2. Ibuprofen 3. Erythromycin 4. Warfarin sodium 5. Amoxicillin (Amoxil) Answer: 1, 2, 3, 5 Explanation: 1. Aspirin may be prescribed for relief of arthritic symptoms. 2. An NSAID may be prescribed for relief of arthritic symptoms. Ibuprofen is an NSAID. 3. A number of antibiotics may be used to treat Lyme disease, including erythromycin. 4. Warfarin sodium is an anticoagulant. This medication is not indicated in the treatment of Lyme disease. 5. A number of antibiotics may be used to treat Lyme disease, including amoxicillin (Amoxil). Page Ref: 1497 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

30 ..

31) While completing a health history the nurse suspects that a patient is experiencing manifestations of scleroderma. What did the nurse assess to make this clinical decision? Select all that apply. 1. Dysphagia 2. Hypotension 3. Telangiectasias 4. Exertional dyspnea 5. Pursed-lip appearance Answer: 1, 3, 4, 5 Explanation: 1. The patient with visceral organ involvement may have varied symptoms. Dysphagia is common because the motility of the esophagus is affected. 2. Hypotension is not a manifestation of scleroderma. 3. Skin manifestations include telangiectasias. 4. The patient with visceral organ involvement may have varied symptoms. Pulmonary involvement can lead to exertional dyspnea due to impaired gas exchange and right-sided heart failure due to pulmonary hypertension. 5. Facial skin tightening leads to a pursed-lip appearance. Page Ref: 1493 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

31 ..

32) The nurse instructs a patient with Sjögren syndrome on self-care techniques. Which patient statement indicates that teaching has been effective? Select all that apply. 1. "I will take aspirin every morning." 2. "I will use artificial tears as needed." 3. "I will make sure I drink water with each meal." 4. "I will be sure to drink fluids throughout the day." 5. "I will brush my teeth before and after every meal." Answer: 2, 3, 4, 5 Explanation: 1. Aspirin is not indicated in the treatment of Sjögren syndrome. 2. Nurses caring for patients with Sjögren syndrome need to teach measures to protect the patient's eyes. Instill artificial tears as needed. 3. Nurses caring for patients with Sjögren syndrome need to teach measures to protect the patient's oral mucosa. Ensure that the patient has sufficient fluids to drink during meals, because fluids help with chewing and swallowing. 4. Nurses caring for patients with Sjögren syndrome need to teach measures to protect the patient's oral mucosa. Encourage the patient to sip fluids throughout the day. 5. Nurses caring for patients with Sjögren syndrome need to teach measures to protect the patient's oral mucosa. Instruct to perform frequent oral hygiene, particularly before and after meals. Page Ref: 1495 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 40.3 Describe the pathophysiology and manifestations of autoimmune and inflammatory musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

32 ..

33) The healthcare provider suggests that a patient with scoliosis participate in conservative treatment. What should the nurse instruct the patient about this treatment approach? Select all that apply. 1. Reduce body weight. 2. Use braces for support. 3. Perform active and passive exercises. 4. Consume 2 to 3 L of fluid each day. 5. Schedule routine injections with corticosteroids. Answer: 1, 2, 3 Explanation: 1. Conservative treatment for adults with scoliosis may include weight reduction. 2. Conservative treatment for adults with scoliosis may include the use of braces for support. 3. Conservative treatment for adults with scoliosis may include active and passive exercises. 4. There is no recommendation to increase fluids in the conservative treatment of scoliosis. 5. Corticosteroid injections are not considered conservative treatment for scoliosis. Page Ref: 1509 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 40.6 Describe the pathophysiology and manifestations of other musculoskeletal disorders, including low back pain, fibromyalgia, spinal deformity, and common foot disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with musculoskeletal disorders.

33 ..

34) A patient is suspected of having osteomyelitis. Which antibiotic should the nurse anticipate being prescribed for this patient? Select all that apply. 1. Nafcillin 2. Oxacillin 3. Cefazolin 4. Ceftriaxone 5. Erythromycin Answer: 1, 2, 3, 4 Explanation: 1. Antibiotic therapy is mandatory to prevent acute osteomyelitis from progressing to the chronic phase. A penicillinase-resistant semisynthetic penicillin such as nafcillin may be given until the culture and sensitivity results are known. 2. Antibiotic therapy is mandatory to prevent acute osteomyelitis from progressing to the chronic phase. A penicillinase-resistant semisynthetic penicillin such as oxacillin may be given until the culture and sensitivity results are known. 3. Antibiotic therapy is mandatory to prevent acute osteomyelitis from progressing to the chronic phase. A cephalosporin such as cefazolin may be given until the culture and sensitivity results are known. 4. Antibiotic therapy is mandatory to prevent acute osteomyelitis from progressing to the chronic phase. A cephalosporin such as ceftriaxone may be given until the culture and sensitivity results are known. 5. Antibiotic therapy is mandatory to prevent acute osteomyelitis from progressing to the chronic phase. Erythromycin is not identified as a medication to treat osteomyelitis. Page Ref: 1498-1499 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.4 Describe the pathophysiology and manifestations of infectious musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

34 ..

35) A patient with a history of intravenous drug abuse is suspected of having septic arthritis. What should the nurse expect to assess in this patient? Select all that apply. 1. Red and swollen joint 2. Pain in the infected joint 3. Anorexia and weight loss 4. Stiffness in the infected joint 5. Joint hot and tender to touch Answer: 1, 2, 4, 5 Explanation: 1. The onset of septic arthritis is typically abrupt, marked by a red and swollen joint. 2. The onset of septic arthritis is typically abrupt, marked by pain in the infected joint. 3. Anorexia and weight loss are not manifestations of septic arthritis. 4. The onset of septic arthritis is typically abrupt, marked by stiffness in the infected joint. 5. The onset of septic arthritis is typically abrupt, marked by a joint that is hot and tender to touch. Page Ref: 1500 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.4 Describe the pathophysiology and manifestations of infectious musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

35 ..

36) An adolescent male patient with a mass on the left femur is experiencing bone pain and impaired function. For which type of bone tumor should the nurse plan care for this patient? Select all that apply. 1. Enchondroma 2. Osteosarcoma 3. Ewing sarcoma 4. Osteochondroma 5. Chondrosarcoma Answer: 1, 2, 3, 4 Explanation: 1. Enchondroma is a benign bone tumor that affects adolescents and young adults. 2. Osteosarcoma is a malignant bone tumor that affects adolescents and young adults. 3. Ewing sarcoma is a malignant bone tumor that affects adolescents and young adults. 4. Osteochondroma is a benign bone tumor that affects children and adolescents. 5. Chondrosarcoma is a malignant bone tumor that affects adults and older adults. Page Ref: 1502 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.3. Implement holistic, patientcentered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 40.5 Describe the pathophysiology and manifestations of neoplastic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

36 ..

37) An adolescent patient is diagnosed with a bony sarcoma of the upper extremity. What should the nurse expect to assess in this patient? Select all that apply. 1. Fever 2. Muscle atrophy 3. Pain that radiates 4. Pain at night or rest 5. Worsening deep bony pain Answer: 2, 3, 4, 5 Explanation: 1. A fever is not a manifestation of a bony sarcoma of the upper extremity. 2. Muscle atrophy is a manifestation of a bony sarcoma of the upper extremity. 3. Radiating pain is a manifestation of a bony sarcoma of the upper extremity. 4. Pain at night or at rest is a manifestation of a bony sarcoma of the upper extremity. 5. Worsening deep bony pain is a manifestation of a bony sarcoma of the upper extremity. Page Ref: 1502 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 40.5 Describe the pathophysiology and manifestations of neoplastic musculoskeletal disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with musculoskeletal disorders.

37 ..

38) A patient with chronic low back pain does not want to use medication for treatment. Which complementary therapy should be recommended to this patient? Select all that apply. 1. Massage 2. Diathermy 3. Chiropractic 4. Acupuncture 5. Hydrotherapy Answer: 1, 3, 4 Explanation: 1. Complementary and alternative medicine strategies for low back pain include massage. 2. Diathermy is a physical therapy application of deep heat and is not considered a complementary therapy. 3. Complementary and alternative medicine strategies for low back pain include chiropractic. Evidence supports the use of spinal manipulation (chiropractic) for treating acute low back pain, finding its effectiveness to be equivalent to conservative medical management. 4. Complementary and alternative medicine strategies for low back pain include acupuncture. 5. Hydrotherapy is a physical therapy use of water and is not considered a complementary therapy. Page Ref: 1505 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.17. Develop a beginning understanding of complementary and alternative modalities and their role in healthcare | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 40.6 Describe the pathophysiology and manifestations of other musculoskeletal disorders, including low back pain, fibromyalgia, spinal deformity, and common foot disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with musculoskeletal disorders.

38 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 41 Assessing the Nervous System 1) The nurse is preparing to assess a patient's cognitive function. What should the nurse include in this assessment? 1. Ability to smell items placed under the nose while eyes are closed 2. Orientation to time, place, and person, and ability to recall recent and past events 3. Ability to walk with a smooth, steady gait 4. Level of consciousness Answer: 2 Explanation: 1. Assessing the patient's ability to smell items placed under the nose while the eyes are closed is the method used to test cranial nerve I, the olfactory nerve. 2. Cognitive function includes orientation to time, place, and person and the ability to recall recent and past events. 3. Gait is not reflective of cognitive function. 4. Level of consciousness is not reflective of cognitive function. Page Ref: 1534 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

1 ..

2) The nurse is preparing to assess a patient's cranial nerve XI (spinal accessory). What should the nurse ask the patient to complete this assessment? 1. Shrug the shoulders and turn the head against resistance. 2. Stick out the tongue and move it from side to side. 3. Taste foods and distinguish sweet from sour. 4. Smell items with one nostril blocked and identify them correctly. Answer: 1 Explanation: 1. Cranial nerve XI, the spinal accessory nerve, is tested by asking the patient to shrug the shoulders and turn the head against resistance. 2. Cranial nerve XII, the hypoglossal nerve, is tested by asking the patient to stick out the tongue and move it from side to side. 3. Cranial nerve VII, the facial nerve, is tested by asking the patient to distinguish among different tastes. 4. Cranial nerve I, the olfactory nerve, is tested by having the patient identify smells correctly with each nostril. Page Ref: 1535 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

2 ..

3) The nurse is preparing to assess a patient's neurologic system. What should the nurse do to assess sensory function? 1. Touch both sides of various parts of the body with a sharp and a dull object. 2. Have the patient distinguish which parts of the body are being touched. 3. Ask the patient to identify two areas of simultaneous pinpricks on the hand. 4. Write a number on the patient's hand and have him or her identify the number. Answer: 1 Explanation: 1. Sensory function is best evaluated by touching both sides of various parts of the body with a sharp and a dull object. 2. This test assesses for localization. 3. This test assesses two-point discrimination. 4. This test assesses for graphesthesia. Page Ref: 1535 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

3 ..

4) The nurse wants to determine if a patient is experiencing tremors. When performing this assessment, for what should the nurse observe? 1. Shaking 2. Jerky movements 3. Rhythmic movements 4. Fasciculations Answer: 3 Explanation: 1. Shaking is a term associated with generalized response to stressors such as cold. 2. Jerky movements would be descriptive of cogwheel rigidity associated with Parkinson disease. 3. Tremors are rhythmic movements seen with activity or at rest. The type of tremors observed is linked to specific disease processes. 4. Fasciculations are twitching, irregular movements associated with motor neuron disease. Page Ref: 1536 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

4 ..

5) A patient is exhibiting a lack of coordination, clumsy movements, and an unbalanced gait. What term should the nurse use when documenting these observations? 1. Flaccidity 2. Paralysis 3. Hemiparesis 4. Ataxia Answer: 4 Explanation: 1. Flaccidity is a reduction in muscle tone associated with disease or trauma of the lower motor neurons and early stroke. 2. Paralysis is an abnormal condition in which movement does not occur at all in a part of the body. 3. Hemiparesis is an abnormal condition in which movement does not occur at all in half of the body. 4. Ataxia is characterized by a lack of coordination, clumsy movements, and an unbalanced gait. Page Ref: 1536 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

5 ..

6) The nurse asks a patient to stand with the feet together and eyes closed. What must the nurse observe for the Romberg test to be considered normal? 1. Swaying from side to side 2. Minimal swaying for up to 20 seconds 3. Sufficient balance to hold completely still without swaying 4. Swaying to one side and loss of balance Answer: 2 Explanation: 1. Swaying should be minimal in the normal test. 2. A normal result of the Romberg test would be the patient displaying minimal swaying for up to 20 seconds. A positive Romberg test, in which the patient sways and may lose balance, is a sign of cerebellar dysfunction as in cerebellar ataxia. 3. Some minimal swaying occurs in the normal individual. 4. Some minor swaying may occur but should not cause loss of balance. The nurse should stand close to the patient to prevent falling. Page Ref: 1536 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.

6 ..

7) The nurse asks the patient to walk heel-to-toe, on the toes, and then on the heels. What function is the nurse assessing? 1. Cerebellar 2. Cerebral 3. Midbrain 4. Brainstem Answer: 1 Explanation: 1. The ability to follow the instructions, walk heel-to-toe, on the toes, then on the heels provides information about the cerebellum. 2. The cerebrum's functions are to interpret sensory input, control skeletal muscle activity, process intellect and emotions, and contain skill memory. 3. The midbrain is a center of auditory and visual reflexes. 4. The brainstem consists of the midbrain (which is the center of auditory and visual reflexes), the pons (which contains nuclei that control respiration), and the medulla oblongata (which plays an important part in controlling cardiac rate, blood pressure, respiration, and swallowing). Page Ref: 1536 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

7 ..

8) While assisting with a lumbar puncture, the nurse determines that a patient's cerebrospinal (CSF) fluid is normal. What did the nurse assess to make this clinical decision? 1. The CSF is yellow, without sediment. 2. The CSF is tinged with blood but has no sediment. 3. The CSF is clear and colorless. 4. The CSF is pink, without sediment. Answer: 3 Explanation: 1. Normal CSF is not yellow. 2. Normal CSF is not blood tinged. 3. Normal CSF is clear and colorless. 4. Normal CSF is not pink. Page Ref: 1525 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.

8 ..

9) The nurse is assessing a patient's muscle strength and movement. What should the nurse do when completing this assessment? 1. Grade the posterior tibial pulses. 2. Grade flaccidity. 3. Observe whether strength and movement are bilaterally equal and strong. 4. Ask the patient to walk normally in a heel-to-toe sequence. Answer: 3 Explanation: 1. Pulses relate to blood supply, not muscles. 2. It is not possible to grade flaccidity. When muscles are flaccid, there is no movement. 3. The nurse should compare one side to the other and note any difference in strength or movement. 4. Asking the patient to walk normally in a heel-to-toe sequence assesses gait, not muscle strength and movement. Page Ref: 1536 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

9 ..

10) The patient has lower motor neuron injuries. What type of reflexes should the nurse expect to assess in this patient? 1. Decreased 2. Increased 3. Normal 4. Exaggerated Answer: 1 Explanation: 1. The finding of abnormally decreased reflexes points to disorders or diseases involving lower motor neuron impairment. 2. The reflexes will not be increased. 3. The reflexes will not be normal. 4. The reflexes will not be exaggerated. Page Ref: 1537 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

10 ..

11) A patient in the supine position with the head flexed to the chest is not experiencing any pain, resistance, or flexion of the hips or knees. What is the nurse assessing in this patient? 1. Doll's-eyes reflex 2. Brudzinski sign 3. Babinski reflex 4. Kernig sign Answer: 2 Explanation: 1. Assessing the direction in which the eyes move when the head is turned tests for the doll's-eyes reflex. 2. The Brudzinski sign is elicited by placing the patient in a supine position and flexing the neck toward the chest. A positive result would be noted if the patient has pain or flexes the hip or knees and indicates meningeal irritation. 3. Testing for the Babinski reflex involves gently scraping the sole of the foot with a blunt object. 4. To assess for Kernig sign, the nurse has the patient, in the supine position, flex the knees and hips, then straighten the knee. Page Ref: 1538 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

11 ..

12) The nurse is planning to assess an adult patient with a neurological problem for abnormal posturing. For what posture should the nurse specifically assess? Select all that apply. 1. Decorticate 2. Decerebrate 3. Circumduction 4. Festinating 5. Nystagmus Answer: 1, 2 Explanation: 1. In decorticate posturing, the upper arms are close to the sides; the elbows, wrists, and fingers are flexed; the legs are extended with internal rotation; and the feet are plantar flexed. 2. In decerebrate posturing, the neck is extended; the jaw is clenched; the arms are pronated, extended, and close to the sides; the legs are extended straight out; and the feet are plantar flexed. 3. Circumduction refers to the circular movement of a limb. 4. Festinating describes a gait abnormality. 5. Nystagmus is the term for involuntary eye movements seen in stroke patients. Page Ref: 1538 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

12 ..

13) A patient is suspected of having a neuromuscular disease. What neurological test helps to diagnose this type of health problem? 1. Single-photon emission computed tomography (SPECT) 2. Positron emission tomography (PET) 3. Magnetic resonance imaging (MRI) 4. Electromyogram (EMG) Answer: 4 Explanation: 1. A SPECT is a nuclear scan that provides information about blood flow. 2. A PET scan provides information about cellular function and is useful in the diagnosis of heart disease and cancers. 3. An MRI uses magnetic fields to produce images of body structures. 4. An EMG measures the electrical activity of skeletal muscles at rest and during contraction and is useful in diagnosing neuromuscular disease. Page Ref: 1540 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.

13 ..

14) A patient in the hospital critical care unit is being evaluated for brain death. What neurological test should the nurse expect to be prescribed for this patient? 1. Electroencephalogram (EEG) 2. Computed tomography (CT) 3. Evoked potentials 4. Electromyogram (EMG) Answer: 1 Explanation: 1. An electroencephalogram (EEG) is part of the brain death protocol in hospitals. It measures the electrical activity of the brain and can also be used to diagnose brain disease. 2. Computed tomography (CT) looks at the intracranial contents and can help distinguish hemorrhage, tumors, cysts, aneurysms, edema, ischemia, atrophy, and tissue necrosis. 3. The evoked potentials test measures nerve conduction along pathways to evaluate muscle contractions. 4. An electromyogram (EMG) measures the electrical activity of skeletal muscles. Page Ref: 1539 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.

14 ..

15) A patient is in the hospital with suspected intracerebral hemorrhage. Which neurologic test is most likely to be prescribed for this patient? 1. X-rays of the spine 2. Computed tomography (CT) 3. Evoked potentials 4. Electroencephalogram (EEG) Answer: 2 Explanation: 1. Spine x-rays provide information about the bony structures of the spine and would not be useful in the diagnosis of intracerebral hemorrhage. 2. A computed tomography (CT) scan can visualize intracerebral hemorrhages because the computer-assisted x-rays view several levels of cross-sections of the head. 3. Evoked potentials look at electrical activity and would not be helpful in the diagnosis of intracerebral hemorrhage. 4. EEG looks at electrical activity and would not be helpful in the diagnosis of intracerebral hemorrhage. Page Ref: 1539 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.

15 ..

16) A victim who was thrown 50 feet in a motor vehicle crash experiences transient consciousness en route to the emergency department. What neurological tests should the nurse expect to be prescribed for this patient? 1. Magnetic resonance imaging (MRI) and computed tomography (CT) 2. Computed tomography (CT) and positron emission tomography (PET) 3. X-rays of the skull and spine and computed tomography (CT) 4. Computed tomography (CT) Answer: 3 Explanation: 1. MRI and CT may be helpful but should be combined with another test. 2. CT and PET scans may be helpful but should be combined with another test. 3. It is always important to "clear" the cervical spine by taking x-rays with visualization of all seven cervical vertebrae. A skull x-ray combined with a CT scan to assess for the presence of blood or clots is also important in this case, because ejection from a vehicle usually causes head trauma. 4. CT may be helpful but should be combined with another test. Page Ref: 1539, 1540 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the nervous system.

16 ..

17) The nurse suspects that an older patient is experiencing age-related changes of a decreased number of brain cells, decreased cerebral blood flow, and decreased metabolism. How would these changes affect the plan of care for the patient at home? Select all that apply. 1. Will be distracted after a few minutes on the task 2. Will not be open to learning to perform a dressing change 3. Will be less reliable at completing self-care activities 4. Will have delayed responses if too many stimuli occur 5. Will have an increased risk for falls Answer: 4, 5 Explanation: 1. Older adults do better when learning is limited to 30 minutes at a time, but they can focus for longer than a few minutes. 2. Older adults may have more readiness to learn when the topic is related to previously learned information. 3. There is no proof that the older adult is less reliable, but ability and reliability need to be assessed for each individual. 4. The older adult may need additional time to process and respond to verbal stimuli. 5. Age-related changes can cause slower reflexes, which increase the older adult's risk for falls. Page Ref: 1541 Cognitive Level: Analyzing Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.3 Differentiate considerations for assessing the nervous systems of older adults and veterans. MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.

17 ..

18) The nurse is conducting a seminar on Alzheimer disease (AD) with a group of community members. How should the nurse describe this health problem? Select all that apply. 1. The incidence of AD increases with age. 2. AD tends to run in families. 3. AD is more common in men. 4. AD is caused by a virus. 5. AD is caused by environmental contaminants. Answer: 1, 2 Explanation: 1. The incidence of AD does tend to increase with age. 2. AD is thought to have a familial link. 3. AD is more common in females. 4. The cause of AD is unknown. 5. The cause of AD is unknown. Page Ref: 1532 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

18 ..

19) A patient is being treated for a common neurological disease that is characterized by abnormal cell firing in the brain. For what should the nurse assess in this patient? 1. Loss of consciousness 2. Seizures 3. Decerebrate posturing 4. Headache Answer: 2 Explanation: 1. The symptoms of loss of consciousness have multiple causes (trauma, medications, diet) but are not associated with abnormal cell firing. 2. Abnormal cell firing in the brain causes the recurring seizures characteristic of epilepsy. 3. Decerebrate posturing is caused by serious brain injury, specifically to the cerebellum. 4. The symptoms of headache have multiple causes (trauma, medications, diet) but are not associated with abnormal cell firing. Page Ref: 1532 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

19 ..

20) The family of a patient recovering from a stroke asks what damage to "Broca's area" means. Which is the best response by the nurse? 1. "The way you communicate will have to change." 2. "You'll have to speak very loudly when you talk." 3. "Make sure there are no obstacles in the room, because sight will be a problem." 4. "Perhaps you would like to learn how to provide range-of-motion exercises." Answer: 1 Explanation: 1. Broca's area in the cerebrum promotes the vocalization of words. 2. Auditory stimuli are received and interpreted in the temporal lobe. 3. The occipital lobe receives and interprets visual stimuli. 4. The postcentral gyrus in the somatosensory cortex registers body sensations such as temperature, touch, pressure, and pain. Page Ref: 1525 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

20 ..

21) A patient experiencing extreme emotional stress is observed to be exhibiting both tachycardia and tachypnea. Which component of the patient's nervous system is responsible for normalizing the patient's response? 1. Central 2. Peripheral 3. Sympathetic 4. Parasympathetic Answer: 4 Explanation: 1. The central nervous system acts as a message center that translates signals from other parts of the body. 2. Signals from the body are transported to the central nervous system by the peripheral nervous system. 3. The sympathetic nervous system has stimulated the body. 4. The parasympathetic nervous system is responsible for returning the body's functions to normal after they have been stimulated by the sympathetic system. Page Ref: 1531 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

21 ..

22) During a health history, the nurse plans to assess the functioning of a patient's central nervous system (CNS). Which question should the nurse ask to assess this function? 1. "Do you get dizzy when moving from a sitting to standing position?" 2. "Do you have difficulty adjusting to changes in temperature?" 3. "Do you have difficulty falling asleep in the evening?" 4. "Have you had any weight loss?" Answer: 2 Explanation: 1. Although there is a potential for altered balance and an increase in postural hypotension from a change in the CNS, this assessment finding is mainly regulated by the autonomic nervous system. 2. Temperature regulation is located in the hypothalamus, which is part of the CNS. 3. Sleep patterns are regulated by the reticular formation. 4. Weight loss can be affected by the sensory division of the nervous system. Page Ref: 1525 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

22 ..

23) A patient reports hearing noises when alone in a quiet room. What action should the nurse take? 1. Make sure the patient is referred to a psychiatrist. 2. Document that the patient has a mental illness. 3. Ask if the patient experiences any visual disturbances. 4. Explain to the patient that this is not unusual. Answer: 3 Explanation: 1. Making a referral to a psychiatrist is beyond the scope of practice for the nurse. 2. It is not within the scope of nursing practice to document mental illness. 3. Information about perception difficulties such as visual and/or auditory disturbances is an important part of the health history of the nervous system. The nervous system controls cognition and sensory function, which includes vision and auditory changes. 4. Hearing and vision changes are not usual assessment findings and should be investigated. Page Ref: 1534 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

23 ..

24) The nurse suspects a patient may be experiencing dysfunction related to the acoustic nerve (CN VIII). Which action should the nurse take to minimize the patient's risk for injury? Select all that apply. 1. Identifying the patient's fall risk category 2. Assessing the patient's gag reflex prior to offering food or liquids 3. Assisting the patient with bedside sitting or toileting 4. Assessing the patient's vision using a Snellen chart 5. Placing a red "falls risk" bracelet on the patient's arm Answer: 1, 3, 5 Explanation: 1. Dysfunction of the acoustic nerve can affect equilibrium and result in vertigo or disturbed balance, putting the patient at risk for falls. 2. Dysfunction of the glossopharyngeal (CN IX) and vagus (CN X) nerves is likely to result in a poor or absent gag reflex. 3. Dysfunction of the acoustic nerve can affect equilibrium and increase the risk for falls. Assisting with bedside toileting or sitting would be indicated. 4. A Snellen chart is an eye chart used to measure visual acuity that may be altered due to dysfunction of the optic nerve (CN II). 5. Dysfunction of the acoustic nerve can affect equilibrium and increase the patient's risk for falling. A falls risk bracelet would be indicated. Page Ref: 1530 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Quality & Safety; Practice-KnowHow; Use technologies that contribute to safety | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

24 ..

25) During an assessment, a patient's tongue deviates markedly to the right side. What is the patient most likely exhibiting? 1. Abnormal hypoglossal nerve response 2. First cranial nerve (CN I) damage 3. Sluggish oculomotor response 4. Absence of the Homans sign Answer: 1 Explanation: 1. Cranial nerve XII (hypoglossal) is tested by having the patient stick out the tongue. An abnormal finding is that the tongue deviates to either side. 2. Cranial nerve I is the olfactory nerve and is assessed by having the patient use the sense of smell. 3. Cranial nerve III is the oculomotor nerve and, along with the trochlear and abducens nerves, helps the eye move. 4. Homans sign is a check for thrombophlebitis in the calves. Page Ref: 1535 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

25 ..

26) A patient in the emergency department (ED) has a Glasgow Coma Scale (GCS) score of 8. Which is the most appropriate action by the nurse? 1. Treat the patient's pain. 2. Assess the patient's airway, breathing, and circulation. 3. Obtain a complete history from the patient. 4. Triage the patient with the other ED patients. Answer: 2 Explanation: 1. Another action takes priority. 2. The GCS (Glasgow Coma Scale) is a standardized system for assessing consciousness. A score of 15 indicates full alertness; a score of 8 or less is usually indicative of coma; the lowest possible score is 3. A comatose patient receives high priority, and the nurse will utilize the ABCs of care in this case. Additionally, assessment is the first nursing process. 3. This patient will not be able to respond to questions. 4. The patient should receive priority care in the ED. Page Ref: 1533 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

26 ..

27) The meal tray for a patient with damage to the glossopharyngeal nerve (CN IX) has been delivered. What action should the nurse take first? 1. Tell the patient what food is on the tray. 2. Assess the patient's ability to swallow. 3. Speak loudly and make eye contact with the patient. 4. Assist the patient in identifying where items are on the tray. Answer: 2 Explanation: 1. The optic nerve (CN II) controls vision. 2. The gag reflex and swallowing are controlled by CN IX. 3. Auditory function is controlled by the acoustic nerve (CN VIII). 4. The optic nerve (CN II) controls vision. Page Ref: 1535 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

27 ..

28) The nurse is conducting a health history with a patient exhibiting signs of Parkinson disease. Which question should the nurse ask the patient? 1. "Do you recall if any of your relatives had difficulty holding on to things with their hands?" 2. "Do you remember what you ate for breakfast this morning?" 3. "Is it painful to flex your chin to your chest?" 4. "Did your muscle weakness first occur in your arms or in your legs?" Answer: 1 Explanation: 1. In Parkinson disease (PD), the lack of dopamine production leads to difficulty with movement, tremor, rigidity, and difficulty maintaining posture. It is thought that the disease process results from a complex interaction between genetic and environmental factors. 2. Alzheimer disease progressively degrades cognitive function. 3. The symptoms of multiple sclerosis include Lhermitte sign, a shocklike pain that occurs when the neck is flexed. 4. Arm weakness is associated with amyotrophic lateral sclerosis (ALS). Page Ref: 1532 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

28 ..

29) A patient's reflexes are documented as being 3+. How should the nurse interpret this finding? 1. The patient's reflexes are weaker than normal. 2. The patient's reflexes are normal. 3. The patient's reflexes are stronger than normal. 4. The patient's reflexes are hyperactive. Answer: 3 Explanation: 1. 1+ reflexes are weaker than normal. 2. 2+ reflexes are normal. 3. 3+ reflexes are stronger than normal. 4. 4+ reflexes are hyperactive, with sustained clonus. Page Ref: 1537 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

29 ..

30) A patient with a fine tremor in the right hand and arm asks what a primary essential tremor means. What is the best response by the nurse? 1. "Essential tremor occurs 5 to 10 years before the onset of Parkinson disease." 2. "When essential tremor is a primary disorder, it is usually inherited." 3. "Essential tremor is very rare. It affects only about 100,000 people." 4. "People with essential tremor often go on to develop cardiovascular disease." Answer: 2 Explanation: 1. Essential tremor does not herald Parkinson disease. 2. Essential tremor, as a primary disorder, is usually inherited. 3. Essential tremor occurs in as many as 3 to 4 million people. 4. There is no evidence that essential tremor heralds cardiovascular disease. Page Ref: 1532 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

30 ..

31) The nurse asks a patient who experienced a cerebral vascular accident (CVA) to complete the heel-to-shin test. What is the nurse testing for with this technique? 1. Ataxia 2. Graphesthesia 3. Coordination 4. Spasticity Answer: 3 Explanation: 1. Ataxia is the inability to walk or difficulty walking. 2. Graphesthesia is the ability to discriminate a number traced on the palm. 3. The heel-to-shin test requires the patient to run each heel down each shin, while in a supine position. This technique tests the patient's coordination. 4. Spasticity is an increase in muscle tone associated with disease of the corticospinal motor tract and is not tested with the heel-to-shin technique. Page Ref: 1537 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

31 ..

32) A patient is prescribed a medication that affects the beta1- and beta2-receptors in the body. Which effect of this medication should the nurse expect to assess? Select all that apply. 1. Normal heart rate 2. Improved respiration 3. Lower blood pressure 4. Reduced muscle cramps 5. Increased blood glucose level Answer: 1, 2, 3, 5 Explanation: 1. Beta1-receptors are found in the heart, where they regulate the rate and force of contraction. 2. Beta2-receptors are found in receptor cells of the lungs and help regulate bronchial diameter. 3. Beta2-receptors are found in receptor cells of the arteries and help regulate arterial diameter. 4. Beta1- and Beta2-receptors do not influence muscle cell function. 5. Beta2- receptors are found in receptor cells of the liver and help regulate glycogenesis. Page Ref: 1524 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.

32 ..

33) The nurse is concerned that a patient is experiencing sympathetic nervous system effects after a head injury. What did the nurse assess to make this clinical decision? Select all that apply. 1. Damp skin 2. Cold extremities 3. Heart rate 68 bpm 4. Deep, rapid respirations 5. Elevated blood pressure Answer: 1, 2, 4, 5 Explanation: 1. Stimulation of the sympathetic division exerts effects on target organs or tissues including diaphoresis, leading to damp skin. 2. Stimulation of the sympathetic division exerts effects on target organs or tissues including vasoconstriction of skin blood vessels, leading to cold skin. 3. A heart rate of 68 bpm would be an effect of the parasympathetic division of the autonomic nervous system. 4. Stimulation of the sympathetic division exerts effects on target organs or tissues including dilation of the bronchioles, leading to deep, rapid respirations. 5. Stimulation of the sympathetic division exerts effects on target organs or tissues including vasoconstriction of arteries, leading to an elevated blood pressure. Page Ref: 1529-1530 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

33 ..

34) During a health history, the nurse becomes concerned that a patient is at risk for a neurological problem because of occupational and social hazards. What finding caused the nurse to have this concern? Select all that apply. 1. The patient smokes 1 ppd of cigarettes. 2. The patient and spouse walk the family dog after dinner. 3. The patient works in a chemical plant that manufactures plastic. 4. The patient plays football with college friends every Saturday afternoon. 5. The patient rides a motorcycle in a state where headgear is not mandatory. Answer: 1, 3, 4, 5 Explanation: 1. Self-care issues related to neurological problems include the use of tobacco. 2. Walking the family dog would not increase the risk of developing a neurological problem. 3. Risk factors for the development of neurological problems include occupational hazards, such as exposure to toxic chemicals or materials. 4. Self-care issues related to neurological problems include wearing a helmet when participating in contact sports. 5. Self-care issues related to neurological problems include wearing a helmet when riding a motorcycle. Page Ref: 1531-1532 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.2 Outline the components of the assessment of the nervous system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the nervous system.

34 ..

35) A patient is being evaluated for disease of the lower motor neurons. Which assessment finding should the nurse identify as consistent with this health problem? Select all that apply. 1. Spasticity 2. Flaccidity 3. Steppage gait 4. Fasciculations 5. Muscle atrophy Answer: 2, 3, 4, 5 Explanation: 1. Muscle tone is increased (spasticity) in disease of the corticospinal motor tract. 2. Muscle tone is decreased (flaccidity) in disease or trauma of the lower motor neurons. 3. Steppage gait is noted with disease of the lower motor neurons. 4. Fasciculations occur in disease of or trauma to the lower motor neurons. 5. Atrophy of the muscles is seen with disease of the lower motor neurons. Page Ref: 1528 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 41.1 Describe the anatomy, physiology, and functions of the nervous system and identify abnormal findings that may indicate impairments of the nervous system. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

35 ..

36) An older patient is diagnosed with a new onset of a seizure disorder. What should the nurse recall when planning care for this patient? Select all that apply. 1. Commonly caused by a stroke 2. Post-seizure manifestations will last longer 3. Complex partial seizures are the most common type 4. Commonly caused by arteriosclerosis of the cerebrovascular system 5. Anti-seizure medication is not as effective in controlling the seizures Answer: 1, 2, 3, 4 Explanation: 1. In an older patient, seizures are commonly caused by a stroke. 2. In an older patient, post-seizure manifestations will last longer. 3. In an older patient, complex partial seizures are the most common type. 4. In an older patient, seizures are commonly caused by arteriosclerosis of the cerebrovascular system. 5. Epilepsy that begins in older adults is often easier to control with antiepileptic drugs (AEDs) than that in younger people. Page Ref: 1541 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 41.3 Differentiate considerations for assessing the nervous systems of older adults and veterans. MNL Learning Outcome: 3. Interpret abnormal findings of the nervous system collected during assessment.

36 ..

37) The nurse is preparing a teaching tool to prevent injuries. What should the nurse include to prevent neurologic injuries due to trauma? Select all that apply. 1. Wear seat belts. 2. Practice vehicular safety. 3. Wear helmets when bicycling. 4. Have an annual eye examination. 5. Wear helmets when riding a motorcycle. Answer: 1, 2, 3, 5 Explanation: 1. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as using seat belts. 2. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as using vehicular safety. 3. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as wearing helmets when bicycling. 4. Annual eye examinations are not identified as an action to prevent neurologic injuries due to trauma. 5. Neurologic injuries due to trauma can be prevented with correct use of safety equipment such as wearing helmets when riding a motorcycle. Page Ref: 1541 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 41.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.

37 ..

38) A patient asks what can be done to prevent the development of a neurologic disorder like other family members have developed over the years. What should the nurse recommend to the patient? Select all that apply. 1. Obtain sufficient sleep. 2. Consume a healthy diet. 3. Consider genetic testing. 4. Engage in regular physical activity. 5. Have routine neurologic examinations. Answer: 1, 2, 4 Explanation: 1. General health promotion actions to positively impact neurologic function include obtaining sufficient sleep. 2. General health promotion actions to positively impact neurologic function include consuming a healthy diet. 3. Genetic testing is not identified as a general health promotion action to positively impact neurologic function. 4. General health promotion actions to positively impact neurologic function include engaging in regular physical activity. 5. Routine neurologic examinations are not identified as a general health promotion action to positively impact neurologic function. Page Ref: 1541 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 41.4 Summarize topics that nurses teach to promote healthy tissue integrity across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the nervous system collected during assessment and health promotion activities to support the health of this body system.

38 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 42 Nursing Care of Patients with Intracranial Disorders 1) A patient without a history of previous seizures experiences two tonic‒clonic seizures in succession while the nurse is in the patient's room. List in priority order the actions the nurse should take. Choice 1. Turn the patient on his or her side. Choice 2. Protect patient from environmental harm. Choice 3. Start oxygen via face mask. Choice 4. Reorientation of the patient to time, person, and place. Answer: 1, 2, 3, 4 Explanation: Choice 1. Nursing care of patients during a seizure should first focus on maintaining a patent airway. During a seizure, the tongue may fall back and obstruct the airway, the gag reflex may be depressed, and secretions may pool at the back of the throat. To open and maintain a patent airway, the patient should be turned on his or her side. Choice 2. After ensuring the airway is patent, the nurse should protect the patient from harm. Tonic‒clonic seizures occur without warning, and the patient will have alternating contraction and relaxation of the muscles of all extremities. During the clonic phrase of the seizure, patients are at risk for head injury and fractures of the extremities. Choice 3. After the clonic phase of seizure activity, if needed, oxygen can be administered by face mask. Choice 4. Consciousness returns gradually; it may take hours before the patient is fully aware and alert, and reorientation to person, place, and time can be achieved. Page Ref: 1561-1562 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

1 ..

2) The nurse notes that a patient with damage to the diencephalon region of the cerebrum is demonstrating a breathing pattern where regular periods of deep, rapid breathing are followed by periods of apnea. How should the nurse document this breathing pattern? 1. Cheyne-Stokes respirations 2. Apneustic respirations 3. Neurogenic hyperventilation 4. Ataxic respirations Answer: 1 Explanation: 1. Cheyne-Stokes respirations are a change in breathing pattern, alternating regular periods of deep, rapid breathing with periods of apnea, and are seen in many patient conditions in the clinical setting. 2. Apneustic respiration is a term used to describe an abnormal pattern of breathing characterized by deep, gasping inspiration with a pause at full inspiration followed by a brief, insufficient release. 3. Neurogenic hyperventilation is hyperventilation associated with brain or spine injury. 4. Ataxic respirations are shallow, irregular respirations associated with damage to the medullary respiratory center. Page Ref: 1547 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

2 ..

3) The nurse is caring for a patient who will be evaluated for brain death. What should the nurse expect to be evaluated in this patient? Select all that apply. 1. Absent motor and reflex movements 2. Flat electroencephalogram (EEG) on successive EEGs 3. No spontaneous respiration 4. Pupils are equal and responsive to light 5. Criteria present for at least 15 minutes Answer: 1, 2, 3 Explanation: 1. Absent motor and reflex movements are part of brain death criteria. 2. Flat electroencephalogram (EEG) on successive EEGs is part of brain death criteria. 3. Lack of spontaneous respiration is part of brain death criteria. 4. Pupils that are equal and responsive to light are a sign of pupillary response and indicate brain function. 5. Criteria should be present for 30 minutes to 1 hour and for 6 hours after onset of coma and apnea. Page Ref: 1548 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

3 ..

4) The nurse is caring for a patient with an altered level of consciousness (LOC). Which intravenous fluid should the nurse expect to be prescribed for this patient? 1. Isotonic or hypertonic 2. 0.45% normal saline 3. Dextrose 5% in water 4. Dextrose 5% in 0.45% normal saline Answer: 1 Explanation: 1. Isotonic (0.9% normal saline) or slightly hypertonic (lactated Ringer's) IV solutions are used in the patient with altered LOC. 2. Hypotonic solutions such as 0.45% saline will cause fluid to move into the cells and worsen cerebral edema. 3. Hypotonic solutions such as D5W will cause fluid to move into the cells and worsen cerebral edema. 4. Hypotonic solutions such as D5W in 0.45% normal saline will cause fluid to move into the cells and worsen cerebral edema. Page Ref: 1549 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

4 ..

5) The nurse is caring for an unconscious patient. What should the nurse expect to be prescribed for this patient when the cough reflex disappears? 1. Continuous pulse oximetry instead of intubation 2. Frequent suctioning with a tonsil-tip suction device 3. Close observation as the patient is fed 4. Intubation and mechanical ventilation Answer: 4 Explanation: 1. This patient is at risk for impaired airway and aspiration. Oximetry would be done in addition to intubation. 2. Frequent oropharyngeal suctioning will not adequately protect the airway and the suctioning will cause hypoxia. 3. No unconscious patient should be fed food or fluids. 4. This patient is at risk for impaired airway and aspiration. Oximetry would be done in addition to intubation and mechanical ventilation. Page Ref: 1556 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

5 ..

6) The nurse is caring for a patient recovering from a craniotomy. How should the nurse position this patient? 1. Low Fowler's (head of bed up 30 degrees) 2. Flat 3. High 4. High Fowler's (head of bed up 45 degrees) Answer: 1 Explanation: 1. Place the patient's head at 30 degrees for optimal draining of cerebrospinal fluid and to prevent increased intracranial pressure. 2. The flat position could increase intracranial pressure. 3. The high position would be uncomfortable for the patient recovering from a craniotomy. 4. The high-Fowler's position is not necessary to ensure intracranial pressure is not increased. Page Ref: 1556 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

6 ..

7) A patient is in the emergency department following a head injury. What should the nurse realize as being the most accurate sign of developing increased intracranial pressure (IICP)? 1. Decreasing level of consciousness 2. Elevated diastolic blood pressure 3. Decreasing respiratory rate 4. Pupils are equal Answer: 1 Explanation: 1. The brain is very sensitive to the level of oxygenation. As hypoxia develops, it will negatively affect the level of consciousness. 2. Change in blood pressure is generally a widening pulse pressure. 3. Change in respiratory rate is a late sign of IICP. 4. Size, shape, and responsiveness of the pupils, not simply equality, should be assessed to determine if ICP is increasing. Page Ref: 1557 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

7 ..

8) A patient is described as having decerebrate posturing after a motor vehicle crash. Which position should the nurse expect to assess in this patient? 1. The arms and legs are hyperextended and arms are hyperpronated. 2. The arms are folded over the chest and spasms are rhythmic. 3. The arms are pulled inward and the head is turned to the side. 4. The arms and legs have tonic‒clonic seizure activity. Answer: 1 Explanation: 1. Decerebrate posture is displayed by hyperextension of the arms and legs and hyperpronation of the arms. Decerebration is considered a sign that the patient has a serious injury with a poor prognosis. 2. This does not describe decerebrate posturing. 3. This does not describe decerebrate posturing. 4. This describes a tonic‒clonic seizure. Page Ref: 1548 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

8 ..

9) A patient being treated for a fall has a dilated pupil on the right and a hematoma in the right temporal area. What should these findings indicate to the nurse? 1. The process affecting the pupil is occurring locally on the right side (ipsilateral pupil dilation). 2. The process affecting the pupil is occurring on the opposite side and is unrelated to the right temporal hematoma. 3. The process affecting the right pupil is temporary and soon both pupils will be equal in size. 4. The process causing the right pupil to dilate is a result of a metabolic process. Answer: 1 Explanation: 1. Generally, when a process is occurring locally, the pupil on the same side (ipsilateral) is affected. 2. If the process affecting the pupil were on the opposite side, the left pupil would be dilated. 3. There is not enough information to determine whether the condition is temporary. 4. There is not enough information to determine whether the condition is caused by a metabolic process. Page Ref: 1580 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

9 ..

10) A patient is experiencing status epilepticus. Which medication should the nurse expect to be prescribed for this patient? 1. Lorazepam (Ativan) IV 2. Oral glucose 3. Phenytoin (Dilantin) orally 4. Gabapentin (Neurontin) and lamotrigine (Lamictal) Answer: 1 Explanation: 1. Lorazepam (Ativan) can be used IV to stop the seizure and is an appropriate treatment order. 2. No drug would be given orally during status epilepticus, although glucose IV would be appropriate. 3. The drug needs to be given IV in this situation, and phenytoin (Dilantin) could be an option if ordered IV. 4. The type of drug therapy used to treat epilepsy uses only one drug at a time. Page Ref: 1559 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

10 ..

11) The nurse is identifying problems for a patient with a seizure disorder. Which problem should the nurse identify as being this patient's greatest psychosocial need? 1. Anxiety 2. Self-Care Deficit 3. Altered Activity: Exercise 4. Altered Body Image Answer: 1 Explanation: 1. The patient will exhibit anxiety, manifested in questions about the ability to work, drive a car, and feelings of embarrassment about having a seizure in public. 2. Self-Care Deficit is not a psychosocial problem. 3. Altered Activity: Exercise is not a psychosocial problem. 4. A patient with a seizure disorder will generally not have any alteration in his or her physical appearance that would result in Altered Body Image. Page Ref: 1562 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

11 ..

12) A patient has a head injury caused by a swinging bat. For which type of injury should the nurse plan care for this patient? 1. Contact 2. A deceleration 3. An acceleration-deceleration injury 4. Rotational Answer: 1 Explanation: 1. Contact phenomena injury is sustained when the head is struck by a moving object, such as a swinging bat. 2. Deceleration is not a type of injury. 3. Acceleration-deceleration injury (linear injury) occurs when the head hits an object and the brain rebounds within the skull. 4. Rotational injury occurs when the brain rotates within the skull and hits bony buttresses in the cranial vault. Page Ref: 1578 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

12 ..

13) While riding in a car that hit a tree, a patient's head hit the windshield (coup) and then the brain rebounded within the skull toward the opposite side (contrecoup). For which type of traumatic brain injury should the nurse plan care for this patient? 1. Acceleration-deceleration 2. Rotational 3. Contact 4. Stationary Answer: 1 Explanation: 1. Acceleration-deceleration injury (linear injury) occurs when the head hits an object and the brain rebounds within the skull. 2. Rotational injury occurs when the brain rotates within the skull and hits bony buttresses in the cranial vault. 3. Contact phenomenon injury occurs when the head is hit by a moving object, such as a swinging bat. 4. Stationary is not a type of injury. Page Ref: 1578 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with intracranial disorders.

13 ..

14) Following a fall, a patient experiences a brief loss of consciousness but is now complaining of a headache, has vomited twice, has a dilated pupil on the same side as a hematoma over the temporal area, and is currently having a seizure. What should the nurse anticipate regarding the care of this patient? 1. This is an emergency situation that is likely due to an epidural hematoma and requires surgery. 2. This is a controlled situation once the seizure stops. 3. This is a serious situation in which a subdural hematoma is developing and requires surgery. 4. This is a typical situation seen with most patients who fall and will subside with observation. Answer: 1 Explanation: 1. Classic signs of an epidural hematoma include a loss of consciousness followed by a brief lucid period before rapid deterioration. 2. Because this injury involves a skull fracture that tears an artery, the patient is bleeding uncontrollably into the head. 3. A subdural hematoma would be manifested by drowsiness, confusion, and enlargement of the ipsilateral pupil within minutes of the injury. Hemiparesis and changes in respiratory pattern may soon follow. 4. This patient will require immediate intervention and not simply observation. Page Ref: 1579-1580 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

14 ..

15) A patient has a seizure that involves a blank stare, unresponsiveness to questions, and smacking of the lips that lasts less than a minute. How should the nurse categorize this seizure? 1. Absence 2. Partial 3. Tonic‒clonic 4. Status epilepticus Answer: 1 Explanation: 1. Absence (or petit mal) seizures involve a blank stare, unresponsiveness to questions, and smacking of the lips. 2. A partial seizure involves only one area of the brain. The symptoms displayed are reflective of the area affected and may be muscle contraction of a single body part if the motor cortex is affected. Sensory manifestations may be exhibited by hallucinations or abnormal sensations. 3. Tonic‒clonic seizures involve generalized contraction coupled with impairment of consciousness. 4. Status epilepticus is a term used to describe repetitive seizures with only very brief calm periods in between. Page Ref: 1558 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

15 ..

16) A patient is having a tonic‒clonic seizure. What should the nurse make a priority when caring for this patient? 1. Protect the patient from injury. 2. Insert a bite block to prevent the patient from swallowing the tongue. 3. Ask the staff to hold the patient tightly. 4. Obtain vital signs. Answer: 1 Explanation: 1. Because of the lack of warning with tonic-clonic seizures, head injury, fractures, burns, or motor vehicle crashes may occur secondarily to seizure activity. 2. A bite block is not needed and may injure the patient with forced insertion. 3. The movements of the patient should not be restrained because this can cause injury. 4. The vital signs cannot be measured during a tonic‒clonic seizure. Page Ref: 1559, 1561 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

16 ..

17) The nurse is caring for a patient with migraine headaches. Which medication should the nurse expect to be prescribed prophylactically for this patient? 1. Propranolol hydrochloride (Inderal) 2. Acetaminophen (Tylenol) 3. Zolmitriptan (Zomig) 4. Sumatriptan (Imitrex) Answer: 1 Explanation: 1. Propranolol hydrochloride (Inderal) is a beta-blocker that prevents dilation of vessels in the pia mater and inhibits serotonin uptake. 2. Acetaminophen (Tylenol) is not identified as a medication used to treat migraines. 3. Zolmitriptan (Zomig) is taken once the migraine starts. 4. Sumatriptan (Imitrex) is taken once the migraine starts. Page Ref: 1592 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.8 Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

17 ..

18) The nurse is planning a seminar about headaches for a community group. What type of headache should the nurse describe as having a strong familial connection, affects females three to one over males, and results in lost productivity? 1. Migraine 2. Cluster 3. Stress 4. Sinus Answer: 1 Explanation: 1. Twenty million people experience migraines, which can last from a few hours to several days. Many require emergency department treatment. 2. Cluster headaches are more common in men between the ages of 20 and 40. 3. Stress or tension headaches are associated with stressful events and muscular contraction. 4. Sinus headaches are associated with congestion in the frontal and maxillary sinuses and may be caused by allergy or infection. Page Ref: 1590-1591 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 42.8 Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

18 ..

19) The nurse is caring for a patient with a head injury involving cerebral edema and increased intracranial pressure (IICP). To prevent further transient increases from occurring, the nurse should implement what intervention? 1. Implement measures to help the patient avoid coughing and straining. 2. Position the patient in the supine position with the head of the bed at 30 degrees. 3. Initiate oxygen administration. 4. Initiate and monitor an IV with normal saline. Answer: 1 Explanation: 1. Coughing and straining can cause transient increases in ICP and should be avoided in this situation. 2. Keeping the patient supine at 30 degrees is an appropriate measure to care for this patient, but not helpful in preventing further increases in ICP. 3. Administering oxygen is an appropriate measure to care for this patient, but not helpful in preventing further increases in ICP. 4. Providing an isotonic IV solution is an appropriate measure to care for this patient, but not helpful in preventing further increases in ICP. Page Ref: 1557 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

19 ..

20) A patient is diagnosed with doll's-eye movements. What should the nurse expect to assess in this patient? 1. The eyes remain fixed as the head is turned. 2. The eyes appear to move in the direction opposite to the motion of the head, when the head is gently rotated. 3. The eyes open and close when the neck is flexed and extended. 4. The pupils remain fixed and dilated. Answer: 2 Explanation: 1. If doll's-eye movements are absent, the eyes will remain fixed as the head is turned. 2. Doll's-eye movements are reflexive movements of the eyes in the opposite direction of head rotation. 3. Eye movement upward with passive flexion of the neck and downward with neck extension (not opening and closing of the eyes) is a normal oculocephalic reflex indicating brain function. 4. "Pupils fixed and dilated" does not describe doll's-eye movements. Page Ref: 1547 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.1 Describe the pathophysiology and manifestations of altered level of consciousness, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

20 ..

21) The nurse is caring for a patient who had a craniotomy for a brain tumor and has developed postoperative leakage of cerebrospinal fluid (CSF) from the nose. Which action should the nurse take when caring for this patient? Select all that apply. 1. Keep patient turned on side of leakage and keep the head of the bed elevated 20 degrees. 2. Assess the patient for constant swallowing. 3. Observe for thick, yellow, odorous drainage. 4. Insert sterile packing into the area. 5. Encourage the patient to blow the nose frequently. Answer: 1, 2 Explanation: 1. Appropriate interventions include positioning the patient on the side of leakage if it is from the ear and keeping the head of the bed elevated to 20 degrees if the leak is from the nose. 2. Assess the patient for constant swallowing. 3. Assess the patient for the presence of clear drainage from the nose, ears, or wound. 4. Do not insert packing. 5. Tell the patient to not put a finger in the nose or ear or blow the nose. Page Ref: 1588-1589 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.7 Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

21 ..

22) A patient with a brain tumor asks why a chest x-ray is needed when the tumor is in the head. What is the nurse's most appropriate response? 1. "The physician may be trying to determine if this is a metastatic brain tumor, as the most common source of these tumors is cancer of the lung." 2. "This is just a precautionary measure. The physician often prescribes chest x-rays." 3. "Don't get so upset about this! It's routine. The doctor will talk to you later." 4. "The escort is here to take you to radiology, so we'll discuss this when you return." Answer: 1 Explanation: 1. The most common source of metastatic brain tumors is cancer of the lung. 2. Stating that the x-ray is just a precautionary measure is correct but not the most appropriate response. 3. The nurse should not assume the patient is upset and/or defer acknowledging the patient's concern. 4. The nurse should not defer addressing the patient's concern. Page Ref: 1585 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 42.7 Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

22 ..

23) A patient with increased intracranial pressure is prescribed mannitol (Osmitrol). What should the nurse do when providing this medication? Select all that apply. 1. Use an in-line filter for IV administration. 2. Do not administer the medication if crystals are noted in the solution. 3. Monitor central venous pressure (CVP) and pulmonary artery pressures (PAP) before and every hour throughout administration. 4. Assess patient for signs of fluid retention. 5. Discontinue the drug immediately if the patient complains of a headache. Answer: 1, 2, 3 Explanation: 1. Mannitol should be administered with an in-line filter. 2. The solution should be checked for presence of crystals. If observed, do not administer the solution. 3. Monitoring of CVP and PAP, vital signs, and urinary output should be done before and hourly during administration. 4. The patient should be assessed for signs of dehydration since this medication is a diuretic. 5. Do not discontinue the drug abruptly as rebound migraine headaches may occur. Page Ref: 1555 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

23 ..

24) The nurse instructs a patient on actions to help reduce the onset of migraine headaches. Which patient statement indicates that additional teaching is required? 1. "I will switch to red wine rather than continuing to drink white wine." 2. "Reading food labels is important since I have to avoid tyramine." 3. "I will need to drink caffeine-free soft drinks and coffee from now on." 4. "Stress management classes will be a good approach to take." Answer: 1 Explanation: 1. Suggestions to decrease the incidence of migraine headaches includes reducing or eliminating red wine. 2. Tyramine should be avoided. 3. Caffeine should be avoided. 4. Relaxation techniques can help reduce the onset of migraine headaches. Page Ref: 1593 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 42.8 Describe the pathophysiology and manifestations of headaches, and outline the interprofessional care and nursing care of patients with headache. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

24 ..

25) The nurse is caring for a patient with transient ischemic attack (TIA). Which medication should the nurse expect to be prescribed for this patient? 1. Antiplatelet agents 2. Fibrinolytic therapy 3. Anticoagulant therapy 4. Corticosteroids Answer: 1 Explanation: 1. Antiplatelet agents are often used to prevent TIAs and strokes in patients who have had previous strokes. These drugs prevent clot formation and blood vessel occlusion. They include aspirin, clopidogrel (Plavix), dipyridamole (Persantine), and ticlopidine (Ticlid). 2. Fibrinolytic therapy is used to treat thrombotic stroke. 3. Anticoagulant therapy is often ordered to treat ischemic stroke. 4. Corticosteroids are used to treat cerebral edema. Page Ref: 1569 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

25 ..

26) The nurse is teaching a community education class on warning signs of stroke and transient ischemic attacks (TIAs). What should be included in this presentation? Select all that apply. 1. Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body 2. Sudden confusion, difficulty speaking, or difficulty understanding speech 3. Sudden trouble walking, dizziness, or loss of coordination 4. Arrival time at the hospital should be within three hours of onset for drugs to be effective 5. African Americans are a high-risk group for strokes Answer: 1, 2, 3 Explanation: 1. Warning signs of stroke and TIAs include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body. 2. Warning signs of stroke and TIAs include sudden confusion, difficulty speaking, or difficulty understanding speech. 3. Warning signs of stroke and TIAs include sudden trouble walking, dizziness, or loss of coordination 4. Arrival time focuses on rapid treatment and not warning signs of stroke or TIAs. 5. Cultural frequency of the health problem does not focus on warning signs of stroke or TIAs. Page Ref: 1565 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

26 ..

27) The nurse is caring for a patient in the postoperative unit following carotid endarterectomy. How should the nurse position the patient? 1. On the unoperated side, either in a flat position or with the head of the bed elevated 30 degrees. 2. On the operated side with the head of the bed in semi-Fowler's position. 3. On the unoperated side with a small towel placed directly against the operative site. 4. On the operated side with a pressure dressing over the operative site. Answer: 1 Explanation: 1. Position the patient on the unoperated side and either maintain a flat position or elevate the head of the bed 30 degrees as prescribed. 2. The patient should be positioned on the unoperated side. 3. Pressure on the wound is undesirable. 4. Position the patient on the unoperated side. Pressure on the wound is undesirable. Page Ref: 1570 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

27 ..

28) The nurse is completing discharge teaching to a patient following hospitalization for a seizure disorder who is being prescribed phenytoin (Dilantin). What should the nurse include in these instructions? 1. "Maintain good oral hygiene, use a soft toothbrush, massage the gums, and floss daily." 2. "Carry identification indicating the type of seizures for which you are being treated." 3. "You will need to have your sodium level monitored." 4. "If you skip a dose, make sure you double the dose the next day." Answer: 1 Explanation: 1. Phenytoin causes gingival hyperplasia, which results in soft, enlarged gums that are prone to bleeding. Oral hygiene using a soft toothbrush, massaging the gums, flossing daily, and scheduling regular dental checkups are included in discharge teaching. 2. Carrying identification about the seizure disorder is important but not specific to the patient on phenytoin. 3. Liver function studies and serum calcium levels should be monitored to avoid liver problems and bone demineralization, which are characteristics of phenytoin. 4. Blood levels of antiseizure drugs should be maintained so taking the exact dosage as prescribed is important. Patients should not alter the daily dose without discussing this with their primary care provider. Page Ref: 1560 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

28 ..

29) The nurse is caring for a patient with an intracranial pressure monitoring device. For which potential problem should the nurse plan care for this patient? 1. Possible infection 2. Confusion 3. Changes in skin integrity 4. Changes in mobility status Answer: 1 Explanation: 1. Intracranial monitoring is more invasive than other monitoring devices and disrupts skin and skeletal barriers. It is often used on patients with impaired immune defenses. It necessitates frequent flushing and monitoring and may be an open system, which offers increased opportunity for pathogens to enter and grow. 2. Confusion is not an identified problem for the patient with an intracranial pressure monitoring device. 3. Skin integrity changes would not be considered a priority problem for the patient with an intracranial pressure monitoring device. 4. Changes in mobility status would not be considered a priority problem for the patient with an intracranial pressure monitoring device. Page Ref: 1557 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.2 Describe the pathophysiology and manifestations of increased intracranial pressure, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

29 ..

30) A patient recovering from a stroke has agnosia. What should the nurse do when caring for this patient? 1. Frequently repeat the names of familiar persons and objects in the patient's room when providing care. 2. Help the patient move hands and arms through the motions of combing hair and getting dressed. 3. Speak with a normal tone of voice near the ear on the unaffected side. 4. Talk normally to the patient but allow adequate time for the patient's short responses. Answer: 1 Explanation: 1. Agnosia is the inability to recognize one or more subjects that were previously familiar, which can be visual, tactile, or auditory. The nurse can assist the patient by frequently repeating names of familiar persons and objects in the patient's room when providing care. 2. This would assist the patient who has apraxia. 3. This would be appropriate for a patient with a hearing deficit. 4. This would assist the patient with expressive aphasia. Page Ref: 1567 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

30 ..

31) The nurse is caring for a patient with a seizure disorder who is scheduled for surgery to remove the epileptogenic focus within the cerebral cortex. Which criteria did the patient meet to be a candidate for this type of surgery? Select all that apply. 1. The patient desires to have a family. 2. There is one focal point located within the patient's brain. 3. The patient cannot afford antiseizure medication prescribed. 4. Medications have not been successful to control seizure activity. 5. The patient is unable to hold a fulltime job because of seizure activity. Answer: 2, 4, 5 Explanation: 1. Family planning is not a reason to have elective surgery to remove the epileptogenic focus. 2. Resective surgery, with removal of the epileptogenic focus, is an option for patients whose seizures are not well controlled with AEDs. Candidates for this type of surgery include those who have a unilateral focus. 3. Cost of medication is not a reason to have elective surgery to remove the epileptogenic focus. 4. Resective surgery, with removal of the epileptogenic focus, is an option for patients whose seizures are not well controlled with AEDs. Candidates for this type of surgery include those who are unresponsive to medical management. 5. Resective surgery, with removal of the epileptogenic focus, is an option for patients whose seizures are not well controlled with AEDs. Candidates for this type of surgery include those who have impaired quality of life from seizures. Page Ref: 1561 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.3 Describe the pathophysiology and manifestations of seizures, and outline the interprofessional care and nursing care of patients with seizures. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

31 ..

32) The nurse notes on the surgical schedule that a patient is scheduled for cranial burr holes. For which health problem does the nurse realize this type of surgical approach is indicated? Select all that apply. 1. Ischemic stroke 2. Migraine headache 3. Epidural hematoma 4. Hemorrhagic stroke 5. Acute subdural hematoma Answer: 3, 5 Explanation: 1. Cranial burr holes are not the treatment of choice for an ischemic stroke. 2. Cranial burr holes are not the treatment of choice for migraine headaches. 3. The treatment of choice for epidural hematomas and large acute subdural hematomas is surgical evacuation of the clot. This can often be performed through burr holes made into the skull. 4. Cranial burr holes are not the treatment of choice for a hemorrhagic stroke. 5. The treatment of choice for epidural hematomas and large acute subdural hematomas is surgical evacuation of the clot. This can often be performed through burr holes made into the skull. Page Ref: 1582 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.6 Describe the pathophysiology and manifestations of traumatic brain injuries, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

32 ..

33) The nurse is instructing a patient with a brain tumor about a scheduled craniotomy. What should the nurse include in this teaching? Select all that apply. 1. The tumor is excised. 2. The bone is cut between the burr holes. 3. The bone flap is returned to the opening. 4. A series of burr holes is made in the skull. 5. Plastic material is placed over the opening. Answer: 1, 2, 3, 4 Explanation: 1. A craniotomy is a surgical opening into the cranial cavity. The tumor is excised. 2. A craniotomy is a surgical opening into the cranial cavity. The bone between burr holes is cut. 3. A craniotomy is a surgical opening into the cranial cavity. The bone flap is returned to the opening. 4. A craniotomy is a surgical opening into the cranial cavity. A series of burr holes is made in the skull. 5. Plastic repair to the skull is done with a cranioplasty. Page Ref: 1587 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 42.7 Describe the pathophysiology and manifestations of brain tumors, and outline the interprofessional care and nursing care of patients with brain tumors. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

33 ..

34) While reviewing newly prescribed orders, the nurse begins to prepare a patient to receive plasminogen activator alteplase (tPA). What should the nurse realize about this patient's health problem? Select all that apply. 1. The patient had an ischemic stroke. 2. The patient had a hemorrhagic stroke. 3. The patient has uncontrollable seizure activity. 4. The patient had a stroke less than 3 hours ago. 5. The patient's systolic blood pressure is greater than 200 mmHg. Answer: 1, 4 Explanation: 1. Fibrinolytic therapy, using a tissue plasminogen activator such as recombinant tissue-type plasminogen activator alteplase (tPA), is used to treat ischemic stroke. The drug converts plasminogen to plasmin, resulting in fibrinolysis of the clot. To be effective, it must be given after confirming (with a CT scan) that the patient has not had a hemorrhagic stroke. 2. This medication is not used for hemorrhagic stroke. 3. This medication is not used to control seizure activity. 4. Fibrinolytic therapy, using a tissue plasminogen activator such as recombinant tissue-type plasminogen activator alteplase (tPA), is used to treat ischemic stroke. The drug converts plasminogen to plasmin, resulting in fibrinolysis of the clot. To be effective, it must be given IV within 3 hours of the onset of manifestations. 5. If the blood pressure is sustained at systolic levels >185 mmHg, the patient cannot be treated with IV tPA. Page Ref: 1569-1570 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 42.4 Describe the pathophysiology and manifestations of stroke, and outline the interprofessional care and nursing care of patients with stroke. MNL Learning Outcome: 2. Consider intraprofessional care for patients with intracranial disorders.

34 ..

35) A patient is brought for medical care with symptoms of a ruptured cerebral aneurysm. Which should the nurse expect to assess in this patient? Select all that apply. 1. Photophobia 2. Muscle cramps 3. Severe neck pain 4. Nausea and vomiting 5. Sudden excruciating headache Answer: 1, 3, 4, 5 Explanation: 1. The manifestations of a ruptured intracranial aneurysm include photophobia due to meningeal irritation. 2. Muscle cramps are not identified as a manifestation of a ruptured intracranial aneurysm. 3. The manifestations of a ruptured intracranial aneurysm include severe neck pain. 4. The manifestations of a ruptured intracranial aneurysm include nausea and vomiting. 5. The manifestations of a ruptured intracranial aneurysm include a sudden explosive headache. Page Ref: 1576 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 42.5 Describe the pathophysiology and manifestations of intracranial vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with intracranial disorders.

35 ..

36) A patient is diagnosed with a stable arteriovenous malformation of the right parietal lobe. What teaching should the nurse provide to this patient? Select all that apply. 1. Engage in regular exercise. 2. Limit sodium and water intake. 3. Engage in stress-reduction activities. 4. Take antiseizure medication as prescribed. 5. Take antihypertensive medication as prescribed. Answer: 3, 4, 5 Explanation: 1. Preventive measures for intracranial aneurysms focus on healthy lifestyle choices such as getting regular exercise. 2. There is no reason for a patient with a stable arteriovenous malformation to limit sodium and water intake. 3. Nursing care depends on the condition of the malformation. If hemorrhage has not occurred, teach the patient to avoid activities that raise blood pressure or could cause injury. 4. Nursing care depends on the condition of the malformation. If hemorrhage has not occurred, the patient is usually given medications to prevent seizures. 5. Nursing care depends on the condition of the malformation. If hemorrhage has not occurred, the patient is usually given medications to control blood pressure. Page Ref: 1577-1578 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 42.5 Describe the pathophysiology and manifestations of intracranial vascular disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with intracranial disorders.

36 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 43 Nursing Care of Patients with Spinal Cord Disorders and CNS Infections 1) A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this patient? 1. Fluid maintenance 2. Changes in mobility 3. Problems with the airway 4. Altered blood flow Answer: 3 Explanation: 1. There is no reason to believe that this patient will have issues maintaining fluid balance. 2. Although this patient has a cervical spinal cord injury that will affect mobility, this is not the priority problem at this time. 3. Because the injury is in the cervical area, the patient is at risk for losing the ability to maintain respirations and clear the airway. This is the priority for the patient at this time. 4. After another intervention is performed, the next priority problem would be blood flow maintenance. Page Ref: 1605 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

1 ..

2) A patient recovering from a spinal cord injury (SCI) is experiencing gastric distress. Which medication should the nurse expect to be prescribed for this patient? 1. Omeprazole (Prilosec) 2. Dopamine (Intropin) 3. Baclofen (Lioresal) 4. Dantrolene (Dantrium) Answer: 1 Explanation: 1. Proton pump inhibitors such as omeprazole (Prilosec) are often administered to prevent stress-related gastric ulcers, a common complication in SCI. 2. Vasopressors are used in the immediate acute care phase to treat bradycardia or hypotension due to spinal and neurogenic shock. Dopamine (Intropin) is used to treat hypotension in neurogenic shock. 3. Antispasmodics such as baclofen (Lioresal) may be used to treat spasticity in patients with spinal cord injury. 4. Antispasmodics such as dantrolene (Dantrium) may be used to treat spasticity in patients with spinal cord injury. Page Ref: 1603 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

2 ..

3) A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. Calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography. Answer: 2 Explanation: 1. A calm, soothing environment is fine, but not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. 2. Autonomic dysreflexia occurs in patients with injury at level T6 or higher and is a lifethreatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. 3. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider. 4. This would not be an initial response for this patient. Page Ref: 1601 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

3 ..

4) A school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, what should the nurse do? 1. Assess the neck for movement. 2. Place the patient on the side to prevent aspiration. 3. Immobilize the neck, securing the head. 4. Try to rouse the patient by gently shaking the shoulders. Answer: 3 Explanation: 1. Guidelines for emergency care include avoiding flexing, extending, or rotating the neck. Assessing the neck for movement could cause or exacerbate a cervical injury. 2. If the patient vomits, the nurse should use the log-roll technique to turn the patient while keeping the head, neck, and spine in alignment. However, the side-lying position should not be used in the immediate emergency care of this patient. 3. Guidelines for emergency care include immobilizing the neck and securing the head. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. 4. Rousing the patient by shaking could cause damage to the spinal cord. Page Ref: 1602 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

4 ..

5) The healthcare provider prescribes 2.5 mg IV of morphine sulfate to be administered to a patient with a ruptured intervertebral disk whose pain has not been controlled with NSAIDs and muscle relaxants. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe? ________ mL Calculate the exact dosage. Answer: 0.25 Explanation: The nurse can use the equation Dosage Required/Dosage Available × 1 mL. For this situation, the equation would be 2.5 mg/10 mg × 1 mL = 2.5/10 × 1 mL = 0.25 × 1 mL = 0.25 mL. Page Ref: 1613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

5 ..

6) The healthcare provider prescribes 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5-milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe? ________ mL Calculate the exact dose. Answer: 1.25 Explanation: The nurse can use the equation Dosage Required/Dosage Available × 1 mL. For this situation, the equation would be 15 mg/60 mg × 5 mL = 15/60 × 5 mL = 0.25 × 5 mL = 1.25 mL. Page Ref: 1613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

6 ..

7) A hospitalized patient with a C7 cord injury yells, "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and ask for a radiologic evaluation. 3. Prepare the patient for surgery because the injury is worsening. 4. Explain that this could be a common, temporary problem. Answer: 4 Explanation: 1. The nurse should explain to the patient what is happening. 2. The healthcare provider does not need to be contacted. Radiologic evaluation is not necessary. 3. Surgery is not indicated at this point as loss of sensation below the injury may occur. 4. Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, possibly bowel and bladder dysfunction, and loss of ability to perspire below the injury level. Page Ref: 1600 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

7 ..

8) A nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Arrange the actions the nurse should take in the correct order, starting with the first. All options must be used. Choice 1. Check the victim's breathing. Choice 2. Check the victim's pulse. Choice 3. Check the victim's airway. Choice 4. Immobilize the spine. Choice 5. Check for the victim's responsiveness. Answer: 5, 3, 1, 2, 4 Explanation: In an emergency situation, the nurse first assesses the patient's level of consciousness during the primary survey of CPR. All people who have sustained trauma to the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury. Prehospital management includes rapid assessment of the ABCs (airway, breathing, circulation) and then immobilizing and stabilizing the head and neck. Page Ref: 1602 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

8 ..

9) A patient with a spinal cord injury (SCI) is placed in traction. Which action should the nurse include when caring for this patient? Select all that apply. 1. Modifying the traction weights as needed 2. Assessing the patient's skin integrity 3. Applying the traction upon admission 4. Administering pain medication 5. Providing passive range of motion Answer: 2, 4, 5 Explanation: 1. The weights on the traction device must not be changed without the order of a healthcare provider. 2. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. 3. The healthcare provider is responsible for initially applying the traction device. 4. The patient in traction is likely to experience pain. The nurse is responsible for assessing the pain and administering the appropriate analgesic as ordered. 5. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or the nurse. Page Ref: 1605-1606 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

9 ..

10) The nurse is educating a patient and the family about different types of stabilization devices. Which statement indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long." Answer: 2 Explanation: 1. The patient's pain level is not dependent on the type of stabilization device used. 2. Unlike Gardner-Wells tongs, the halo device does not require weights, allowing the patient greater mobility. 3. Gardner-Wells tongs do not carry a great risk of infection; both devices require pins to be inserted into the skull. 4. The time required for stabilization is not dependent on the type of stabilization device used. Page Ref: 1603 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

10 ..

11) A patient with a spinal cord injury was given IV dexamethasone (Decadron) after arriving in the emergency department. What assessment finding should the nurse attribute to the steroid medication? 1. Hypoglycemia 2. Less spinal shock 3. Urinary retention 4. Muscle spasms Answer: 2 Explanation: 1. A common side effect of corticosteroids is hyperglycemia. 2. In the patient with a spinal cord injury, corticosteroids may be used to reduce or control inflammation and edema of the cord, which can lead to less spinal shock. 3. Steroids do not cause urinary retention. 4. Steroids do not cause muscle spasms. Page Ref: 1602 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

11 ..

12) The nurse is caring for a patient recovering from a laminectomy. Which action should the nurse take to prevent skin breakdown in this patient? 1. Provide an air mattress. 2. Place pillows under the patient to help with turns. 3. Teach to grasp the side rail to turn. 4. Use log rolling to turn to the side. Answer: 4 Explanation: 1. An air mattress will help prevent skin breakdown, but the patient still needs to be turned frequently. 2. Placing pillows under the patient can help take pressure off one side, but the patient still needs to change positions often. 3. Teaching the patient to grasp the side rail will cause the spine to twist, which should be avoided. 4. A patient who has undergone a laminectomy needs to be turned by log-rolling to prevent pressure on the area of surgery and ensure healing. Page Ref: 1613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

12 ..

13) The nurse is planning care for a patient recovering from spinal fusion surgery. What should the nurse identify as a goal of care for this patient? Select all that apply. 1. Maximizing comfort 2. Controlling pain 3. Promoting body alignment 4. Preventing injury 5. Promoting nutritional intake Answer: 1, 2, 3, 4 Explanation: 1. The goals of care for the patient recovering from spinal surgery include maximizing comfort. 2. The goals of care for the patient recovering from spinal surgery include providing effective pain management. 3. The goals of care for the patient recovering from spinal surgery include promoting correct body alignment. 4. The goals of care for the patient recovering from spinal surgery include preventing further injury. 5. Promoting nutritional intake is not a goal of care for the patient recovering from spinal surgery. Page Ref: 1613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

13 ..

14) The nurse is preparing an educational session about spinal cord injury (SCI) prevention for a community group. What patient example should the nurse use to explain the risk factors for this type of injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 28-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team Answer: 1 Explanation: 1. The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. 2. In spite of the substance abuse, this female would have a lower overall risk for SCI than another example. 3. This female is not at increased risk for spinal cord injuries. 4. This man is not at increased risk for spinal cord injuries. Page Ref: 1625 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: High Risk Behaviors Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

14 ..

15) The nurse understands that when the spinal cord is injured, ischemia and edema result. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury two cord segments above and below the affected level." 3. "Neurons need time to regenerate, so stating the extent of injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury." Answer: 2 Explanation: 1. Tissue repair occurs over a period of 3 to 4 weeks. 2. Within 24 hours, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. 3. Neurons do not regenerate. 4. Within 24 hours, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Page Ref: 1598 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

15 ..

16) A patient with a spinal cord injury is recovering from spinal shock. What can occur if the patient develops a full bladder? 1. Autonomic dysreflexia 2. Autonomic crisis 3. Autonomic shutdown 4. Autonomic failure Answer: 1 Explanation: 1. Autonomic dysreflexia is triggered by stimuli that would normally cause abdominal discomfort, by stimulation of pain receptors, and by visceral contractions. The most common cause is a full bladder. 2. Autonomic crisis is not a term used to describe common complications of spinal injury associated with bladder distention. 3. Autonomic shutdown is not a term used to describe common complications of spinal injury associated with bladder distention. 4. Autonomic failure is not a term used to describe common complications of spinal injury associated with bladder distention. Page Ref: 1601 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

16 ..

17) While caring for a patient with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every 2 to 3 minutes while searching for the cause in order to prevent loss of consciousness or death. By completing these interventions, which health problem is the nurse preventing as the most dangerous complication of autonomic dysreflexia? 1. Hypoxia 2. Bradycardia 3. Elevated blood pressure 4. Tachycardia Answer: 3 Explanation: 1. Hypoxia is not the most dangerous complication of autonomic dysreflexia. 2. Bradycardia is not the most dangerous complication of autonomic dysreflexia. 3. Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. 4. Tachycardia is not the most dangerous complication of autonomic dysreflexia. Page Ref: 1606 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

17 ..

18) A patient with a secondary metastatic spinal cord tumor is scheduled for surgery. What should the nurse recognize as the goal of surgery for this patient? 1. Complete removal of the tumor and affected spinal cord tissue 2. Eradication of the tumor with excision and drainage 3. Tumor excision to reduce cord compression 4. Exploration to visualize the tumor and obtain a biopsy Answer: 3 Explanation: 1. Complete removal of the tumor and affected spinal tissue would not be likely due to the secondary nature of the tumor and the resulting disability. 2. Eradication by excision and drainage would not be likely due to the secondary nature of the tumor and the resulting disability. 3. The tumor can exert pressure on the spinal cord, which interferes with function. In the case of secondary metastatic spinal tumor, the patient outcome may be limited to preventing compression on the spinal cord rather than completely removing the cancerous lesion. 4. Biopsy can be accomplished without direct visualization. Page Ref: 1617 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

18 ..

19) A patient with a spinal cord injury (SCI) has complete paralysis of both upper and lower extremities. Which term should the nurse use when documenting this patient's status? 1. Hemiplegia 2. Paresthesia 3. Paraplegia 4. Quadriplegia Answer: 4 Explanation: 1. Hemiplegia is paralysis on one side of the body. 2. Paresthesia does not include paralysis. 3. Paraplegia is paralysis of the lower body. 4. Quadriplegia is the complete paralysis of the upper extremities and lower part of the body. Page Ref: 1599 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

19 ..

20) A patient with a spinal cord injury has a blood pressure of 90/60 mmHg, flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. Which health problem should the nurse suspect is occurring with this patient? 1. Paralysis 2. Spinal shock 3. High cervical injury 4. Temporary hypovolemia Answer: 2 Explanation: 1. The findings describe paralysis that would be associated with another condition in a spine-injured patient. 2. Spinal shock is the response of the cord itself to injury. It involves temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord. As a result of the injury, sympathetic function is interrupted and parasympathetic function is unopposed. This condition is characterized by flaccid paralysis, loss of skin reflexes and deep tendon reflexes, and loss of all sensations below the level of injury. There is loss of urinary bladder tone. The autonomic dysfunction results in hypotension. 3. Lack of respiratory effort is generally associated with high cervical injury. 4. The likely cause of these findings is not hypovolemia. Page Ref: 1600 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

20 ..

21) An unconscious patient receiving emergency care following a motor vehicle crash has a possible spinal cord injury. What guideline for emergency care should be followed? Select all that apply. 1. Immobilize the patient's neck using rolled towels or a cervical collar. 2. Place the patient in a supine position. 3. Place the patient on a ventilator. 4. Elevate the head of the bed. 5. Secure the patient's head with a belt or tape secured to the stretcher. Answer: 1, 2, 5 Explanation: 1. In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious, should be treated as though they have a spinal cord injury. The patient's neck should be immobilized with rolled towels or a cervical collar. 2. In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious, should be treated as though they have a spinal cord injury. The patient should be maintained in the supine position. 3. Placement on a ventilator will be considered after admission to the hospital. 4. Raising the head of the bed will be considered after admission to the hospital. 5. In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious, should be treated as though they have a spinal cord injury. The patient's head should be secured by placing a belt or tape across the forehead and securing it to the stretcher. Page Ref: 1602 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; PracticeKnow-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

21 ..

22) The nurse suspects that a patient with a spinal cord injury is experiencing autonomic dysreflexia. Which finding will help the nurse determine the cause for this health problem? Select all that apply. 1. Hypertension 2. Kinked catheter tubing 3. Respiratory wheezes and stridor 4. Diarrhea 5. Fecal impaction Answer: 2, 5 Explanation: 1. Hypertension is a manifestation of autonomic dysreflexia. 2. Autonomic dysreflexia can be caused by kinked catheter tubing, which allows the bladder to become full and triggers massive vasoconstriction below the injury site, producing the manifestations of this process. 3. Respiratory system changes do not cause autonomic dysreflexia. 4. Diarrhea does not cause autonomic dysreflexia. 5. Fecal impaction can trigger autonomic dysreflexia. Page Ref: 1606 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

22 ..

23) An industrial nurse is conducting a class on ways to prevent back pain. What should the nurse include when teaching about lifting heavy objects? Select all that apply. 1. Spread the feet apart to broaden the base of support. 2. Use the legs to push when lifting. 3. Stand as closely as possible to the object to be moved. 4. Squat and use the thigh muscles. 5. Bend at the waist over the center of gravity. Answer: 1, 2, 3, 4 Explanation: 1. The feet should be spread apart to broaden the base of support. 2. The large muscles of the legs should be used to push when lifting. 3. The body should be positioned as close to the object as possible before lifting or moving it. 4. The person should squat and use the thigh muscles when lifting. 5. Bending at the waist is not recommended. Page Ref: 1615 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

23 ..

24) The nurse is preparing an educational program on bacterial meningitis for a group of community members. Which group should the nurse identify as being at greatest risk for this infection? Select all that apply. 1. Older adults 2. Pregnant women 3. Military recruits 4. College students 5. Low-income individuals Answer: 3, 4 Explanation: 1. Older adults are at a low risk for bacterial meningitis. 2. Pregnant women are at a low risk for bacterial meningitis. 3. Military personnel living on a base are at a greater risk of contracting bacterial meningitis. 4. Young adults living in close proximity (such as college students living in a dormitory) are at a greater risk of contracting bacterial meningitis. 5. Low-income individuals are at a low risk for bacterial meningitis. Page Ref: 1618 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

24 ..

25) A patient had the poliomyelitis virus decades ago. What should the nurse expect when assessing the patient with post-poliomyelitis syndrome now? 1. Progressive muscle weakness, fatigue, and pain; muscle atrophy and scoliosis 2. A new outbreak of polio and the need for a new immunization 3. Respiratory complications that must be quarantined 4. Active polio Answer: 1 Explanation: 1. The manifestations of post-poliomyelitis syndrome include progressive muscle weakness, fatigue, and pain, leading to muscle atrophy and scoliosis. 2. The presence of the post-poliomyelitis syndrome does not indicate that a resurgence of polio is likely. 3. The respiratory complications that may occur would be related to muscular weakness and would not require quarantine. 4. Having post-poliomyelitis syndrome does not mean the patient has active polio. Page Ref: 1624 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

25 ..

26) A patient being treated for cat scratches is concerned about tetanus. Which method should the nurse describe as a way to completely prevent the development of tetanus? 1. Active immunization 2. Debriding the bite wound 3. Passive immunization 4. Administering antibiotics immediately after a bite Answer: 1 Explanation: 1. Active immunization is achieved if a tetanus booster is given every 10 years. 2. Debridement of the wound will not prevent infection. 3. Tetanus is not prevented by passive immunity. 4. Antibiotics are used in the treatment of tetanus but do not prevent it. Page Ref: 1623 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

26 ..

27) A patient is admitted to the hospital with a suspected case of botulism. The nurse recognizes that which situation likely caused this infection? 1. The patient ate food contaminated with the toxin. 2. The patient came in contact with someone who had botulism. 3. The patient was injected with the poison. 4. The patient had a dirty wound that became infected with the toxin. Answer: 1 Explanation: 1. Botulism is food poisoning that takes several hours to develop after ingesting contaminated food such as improperly canned or cooked foods and especially home-canned vegetables and fruits, smoked meats, and vacuum-packed fish. 2. Botulism is not contagious. 3. It is unlikely that the patient was injected with the bacteria. 4. Botulism does not result from an infected wound. Page Ref: 1624 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

27 ..

28) During a health fair, a participant asks why food should not be eaten from a "bulging" can. How should the nurse respond? 1. "It may be a sign that botulism toxins are present, because the food has been improperly processed and sealed." 2. "Arboviruses may be found in canned foods that appear damaged." 3. "The bacteria Clostridium tetani grows in poorly processed foods or damaged cans." 4. "Open the can, and if no bubbles, bad odor, or change in color is present, you can eat the contents." Answer: 1 Explanation: 1. The botulism bacillus (Clostridium botulinum) is found in the soil. Cases of botulism result from eating improperly canned or cooked foods, especially home-canned vegetables, fruits, smoked meats, and vacuum-packed fish. Signs that food may be contaminated with botulism include damaged seals on a container, gas bubbles, a bad odor, or a color change in the food. 2. Arboviruses are spread by ticks and mosquitoes. 3. Clostridium tetani causes tetanus. 4. A bulging can is a sign that botulism may be present. The can should not be opened or the contents eaten. Page Ref: 1624 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

28 ..

29) A patient is experiencing symptoms of post-poliomyelitis syndrome. What should the nurse recall about this health problem? 1. The initial infection occurred in the 1940s and 1950s. 2. The patient will have muscle involvement only in muscle groups that were affected initially. 3. The patient will have few symptoms other than mild muscle and joint weakness and pain. 4. The patient had a recurrence due to receiving an oral polio vaccine booster. Answer: 1 Explanation: 1. Post-poliomyelitis syndrome is a complication of a previous infection by the poliomyelitis virus. Polio was an epidemic in the 1940s and 1950s but has largely been eradicated through immunization with oral live trivalent virus vaccine. It is estimated that nearly 25% to 40% of the people in the United States who had contracted the disease are reexperiencing acute manifestations. 2. Manifestations involve muscles that were initially infected as well as new muscle groups. 3. The manifestations include progressive muscle weakness, fatigue, and pain, leading to muscle atrophy and scoliosis. 4. The cause of this syndrome is unknown. Page Ref: 1624 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

29 ..

30) A patient with protruding lumbar disks is scheduled for a laminectomy. What should the nurse instruct the patient about this surgery? Select all that apply. 1. The surgery will relieve pressure on the nerves. 2. A hollow titanium cylinder will be placed over the spine. 3. The spaces where the spinal nerves exit the canal will be enlarged. 4. The bony arch on the surface of the vertebra will be removed. 5. Wedge-shaped pieces of bone will be inserted between the vertebrae. Answer: 1, 4 Explanation: 1. A laminectomy is done to relieve pressure on the nerves. 2. A spinal fusion may be done by placing a hollow titanium cylinder within the spine. 3. Foraminotomy is a surgical procedure to enlarge the space where a spinal nerve exits the spinal canal. 4. A laminectomy is the removal of part of the vertebral lamina, the bony arch on the dorsal surface. 5. A spinal fusion is the insertion of a wedge-shaped piece of bone or bone chips between the vertebrae to stabilize them. Page Ref: 1612 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

30 ..

31) The nurse instructs a patient with herniated thoracic and lumbar disks about spinal fusion surgery. Which patient statements indicate that teaching has been effective? Select all that apply. 1. "Bone chips might be taken from my iliac crest bone." 2. "Holes will be drilled into my skull so that a brace can be placed." 3. "Bone chips will be wedged between the vertebrae to stabilize them." 4. "I will need to stay on bed rest because traction will be applied to my spine." 5. "A hollow titanium tube might be placed in my spine to replace a removed disk." Answer: 1, 3, 5 Explanation: 1. Spinal fusion is the insertion of a wedge-shaped piece of bone or bone chips usually harvested from the patient's ileac crest. 2. Burr holes are not drilled into the skull for a spinal fusion. 3. Spinal fusion is the insertion of a wedge-shaped piece of bone or bone chips between the vertebrae to stabilize them. 4. Spinal fusion surgery does not involve traction. 5. A spinal fusion may be performed through a spinal implant with a hollow titanium cylinder with holes, which is packed with grafted bone from a donor site and placed in the space where a disk is removed. Page Ref: 1612 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

31 ..

32) A patient recovering from a laminectomy reports a pain level of 10 on a scale of 0 to 10 and believes something must be wrong because the pain is worse than it was before the surgery. How should the nurse respond? 1. "The discomfort is not pain but rather muscle spasms." 2. "I'm sure you will need more surgery, so I will be back to get you." 3. "The surgery caused edema of the nerve roots, which increases the amount of pain." 4. "Pain is an indication that something is wrong. I will contact the surgeon." Answer: 3 Explanation: 1. Pain is whatever the patient says it is. Muscle spasms also cause pain. 2. The patient does not need more surgery. 3. The patient recovering from a laminectomy has experienced compression of the nerve root over time, resulting in edema and inflammation. Because of surgery-induced edema, the patient is likely to experience either the same pain or perhaps more severe pain in the period immediately after surgery. 4. The surgeon does not need to be contacted. Page Ref: 1613 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

32 ..

33) The nurse is instructing a patient with a ruptured vertebral disk on self-care measures. What should the nurse include in this teaching? Select all that apply. 1. Bend from the waist. 2. Wear low-heeled shoes. 3. Avoid twisting the back. 4. Sleep on a firm mattress. 5. Use a pillow under the knees when lying down. Answer: 2, 3, 4, 5 Explanation: 1. The patient should be instructed to avoid bending the spine. 2. The patient should be instructed to wear low-heeled or flat shoes. 3. The patient should be instructed to avoid twisting the back. 4. The patient should be instructed to sleep on a firm mattress. 5. When lying in the supine position, the patient should flex the knees to approximately a 45degree angle with a small pillow. Page Ref: 1615 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with spinal cord disorders and CNS infections.

33 ..

34) A patient is diagnosed with a lumbosacral spinal cord tumor. Which medication should the nurse expect to be prescribed for this patient? Select all that apply. 1. Morphine 2. Furosemide (Lasix) 3. Warfarin (Coumadin) 4. Amoxicillin (Amoxil) 5. Dexamethasone (Decadron) Answer: 1, 5 Explanation: 1. The patient with a spinal cord tumor is prescribed medications, typically opioid analgesics, to control pain and edema. 2. Furosemide (Lasix) is not indicated in the treatment of a spinal cord tumor. 3. Warfarin (Coumadin) is not indicated in the treatment of a spinal cord tumor. 4. Amoxicillin (Amoxil) is not indicated in the treatment of a spinal cord tumor. 5. Steroids such as dexamethasone (Decadron) are administered to control cord edema. Page Ref: 1616 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

34 ..

35) The nurse is concerned that a patient with a spinal cord tumor is developing syringomyelia. What did the nurse assess to make this clinical decision? Select all that apply. 1. Pain 2. Spasticity 3. Numbness 4. Leg weakness 5. Cool extremities Answer: 1, 2, 4 Explanation: 1. Syringomyelia is a complication of spinal cord tumors involving formation of a fluid-filled cystic cavity in the central intramedullary gray matter and causing pain. 2. Syringomyelia is a complication of spinal cord tumors involving formation of a fluid-filled cystic cavity in the central intramedullary gray matter and causing spasticity. 3. Syringomyelia does not cause numbness. 4. Syringomyelia is a complication of spinal cord tumors involving formation of a fluid-filled cystic cavity in the central intramedullary gray matter and causing motor weakness. 5. Syringomyelia does not cause cool extremities. Page Ref: 1616 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.1 Describe the pathophysiology and manifestations of spinal cord injuries, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with spinal cord disorders and CNS infections.

35 ..

36) A college student is admitted for treatment of viral meningitis. What should the nurse expect to assess in this patient? Select all that apply. 1. Lethargy 2. Confusion 3. Photophobia 4. Neck stiffness 5. Positive Kernig sign Answer: 1, 3, 4, 5 Explanation: 1. The manifestations of viral meningitis are milder than those of bacterial meningitis and may include lethargy. 2. The manifestations of viral meningitis are milder than those of bacterial meningitis. The patient typically remains oriented. 3. The manifestations of viral meningitis are milder than those of bacterial meningitis and may include photophobia. 4. The manifestations of viral meningitis are milder than those of bacterial meningitis. Neck stiffness is usually present. 5. The manifestations of viral meningitis are milder than those of bacterial meningitis. A positive Kernig sign is usually present. Page Ref: 1619 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with spinal cord disorders and CNS infections.

36 ..

37) A patient with a chronic sinus infection is diagnosed with a brain abscess. What medication should the nurse expect to provide to this patient? Select all that apply. 1. Morphine sulfate 2. Digitalis (Digoxin) 3. Phenytoin (Dilantin) 4. Acetaminophen (Tylenol) 5. Broad-spectrum antibiotic Answer: 3, 4, 5 Explanation: 1. Analgesics that have a depressant effect on the CNS, such as opiates, are avoided to prevent masking of early manifestations of deteriorating level of consciousness (LOC). 2. Digitalis (Digoxin) is not indicated in the care of the patient with a brain abscess. 3. Anticonvulsant medication such as phenytoin (Dilantin) is often prescribed to prevent or control seizure activity. 4. Antipyretic medication may provide symptomatic relief. 5. Antibiotic therapy is the primary treatment for brain abscess. A combination of broadspectrum antibiotics is used if the infecting organism is unknown. Page Ref: 1619-1621 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 43.2 Describe the pathophysiology and manifestations of central nervous system infections, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with spinal cord disorders and CNS infections.

37 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 44 Nursing Care of Patients with Neurologic Disorders 1) The nurse is preparing to care for a patient with Alzheimer disease. What should the nurse identify as a common sign of this disorder? Select all that apply. 1. Poor or decreased judgment 2. Declining job skills 3. Inability to be comfortable in social situations 4. Obsession with organization 5. Focused on abstract thoughts Answer: 1, 2, 3 Explanation: 1. Poor or decreased judgment is a warning signs of AD. This change may make the patient uncomfortable in social situations. 2. Memory loss that negatively affects job skills is a warning sign of AD. This change may make the patient uncomfortable in social situations. 3. These changes may make the patient uncomfortable in social situations. 4. Obsession with organization is not usually associated with Alzheimer disease. 5. A focus on abstract thoughts is not usually associated with Alzheimer disease. Page Ref: 1636 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

1 ..

2) The nurse is reviewing medication orders for a patient with Alzheimer disease. Which medication should the nurse expect to be prescribed for this patient? 1. Rivastigmine tartrate (Exelon) 2. Adrenocorticotropic hormone (ACTH) 3. Meperidine (Demerol) 4. Acetaminophen (Tylenol) Answer: 1 Explanation: 1. Rivastigmine tartrate (Exelon) is used to improve the ability to carry out activities of daily living. It decreases agitation and delusions and improves cognitive function. 2. Adrenocorticotropic hormone (ACTH) is a natural hormone, but it has no known ability to treat Alzheimer disease. 3. Meperidine (Demerol) is a narcotic used to treat moderate to severe pain and would not be indicated in treatment of Alzheimer disease. 4. Acetaminophen (Tylenol) is a nonsteroidal anti-inflammatory medication that would not be used routinely to treat Alzheimer disease. Page Ref: 1633 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.

2 ..

3) The nurse is having a conversation with an older adult with Parkinson disease. What speech pattern would this patient most likely exhibit during conversation with the nurse? Select all that apply. 1. A low-pitched monotone voice 2. Bubbly, spirited discussion 3. Jumbled words that do not make sense 4. Angry, loud talk 5. Slurring and poor articulation of words Answer: 1, 5 Explanation: 1. Voice amplitude is affected by the neuromuscular effects of Parkinson disease. The voice becomes very monotonous with progression of the disease. Patients will need to be reminded to speak loudly. 2. A patient with Parkinson disease will not have a bubbly spirited discussion. 3. Muscular ability may make communication difficult, but the patient will retain cognitive ability, so communication should make sense. 4. A patient with Parkinson disease will not sound angry or have a loud voice. 5. Vocal articulation is affected by the neuromuscular effects of Parkinson disease. Patients will exhibit slowed speaking patterns and will have difficulty articulating clearly. Page Ref: 1652-1653 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

3 ..

4) A patient with Parkinson disease is demonstrating bradykinesia. What should the nurse expect to assess in this patient? 1. Slowed or delayed movements 2. Increased spontaneous movements 3. Active exercise and high energy 4. Very slow talk Answer: 1 Explanation: 1. Parkinson disease creates the slowed or delayed movements typical of bradykinesia. 2. Parkinson disease does not create an increase in spontaneous movements that occur more slowly. 3. High energy and active exercise is difficult for the patient with Parkinson disease. 4. Patients with Parkinson disease do talk slowly, but the term bradykinesia refers to movement. Page Ref: 1647 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

4 ..

5) The nurse notes that a patient with Parkinson disease is experiencing tremors and muscle rigidity. Which medication should the nurse expect to be prescribed for these manifestations? 1. Trihexyphenidyl (Artane) 2. Acetaminophen (Tylenol) 3. Meperidine (Demerol) 4. Nitroglycerin (Nitro-bid) Answer: 1 Explanation: 1. Trihexyphenidyl (Artane) can be used to treat tremors. 2. Acetaminophen (Tylenol) does not affect tremors. 3. Meperidine (Demerol) does not affect tremors. 4. Nitroglycerin (Nitro-bid) does not affect tremors. Page Ref: 1651 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.

5 ..

6) An adult patient with Bell palsy asks if the facial paralysis and distortion will go away. How should the nurse response to this patient? 1. "Most people recover completely within a few weeks to a few months." 2. "Everyone recovers from Bell palsy in three to five weeks." 3. "Most people have permanent facial paralysis on both sides of the face." 4. "Most people have permanent facial paralysis on one side of the face." Answer: 1 Explanation: 1. About 70% of people recover completely from Bell palsy within a few weeks to a few months. 2. Recovery can take longer than 3 to 5 weeks. 3. The facial paralysis will resolve. There will not be permanent paralysis on both sides of the face. 4. The facial paralysis will resolve. There will not be permanent paralysis on one side of the face. Page Ref: 1665 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

6 ..

7) A patient seeks medical attention for excruciating pain on one side of the face. What should the nurse suspect is occurring with this patient? 1. Trigeminal neuralgia 2. Parkinson disease 3. Bell palsy 4. Myasthenia gravis Answer: 1 Explanation: 1. Trigeminal neuralgia is characterized by unilateral excruciating facial pain. 2. This symptom is not associated with Parkinson disease. 3. This symptom is not associated with Bell palsy. 4. This symptom is not associated with myasthenia gravis. Page Ref: 1664 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

7 ..

8) A patient who is newly diagnosed with Huntington disease asks if this disorder can be passed on to future children. What should the nurse say in response to this patient? Select all that apply. 1. "There may be genetic concerns that should be discussed with the physician." 2. "Children will not be affected by the disease." 3. "The disease is passed on genetically in 75% of offspring." 4. "Each child will have a 50% chance of inheriting the gene." 5. "Genetic testing can determine who has the disease. Answer: 1, 4, 5 Explanation: 1. Huntington disease (HD) is a progressive, degenerative, inherited neurologic disease. 2. It is an autosomal-dominant inherited disease. Children have a 50% chance of inheriting the disease. 3. It is an autosomal-dominant inherited disease. Children have a 50% chance of inheriting the disease. 4. It is an autosomal-dominant inherited disease. Children have a 50% chance of inheriting the disease. 5. It is an autosomal-dominant inherited disease and genetic testing will need to be done to determine whether the person is a carrier of the disease before beginning to exhibit manifestations. Page Ref: 1655 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

8 ..

9) The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse recall is the prognosis for this patient? 1. Poor; the disease rapidly progresses and is fatal. 2. Good; the disease will progress over many years but the quality of life will be good. 3. Good; the disease progresses rapidly but can be halted by drug therapy. 4. Excellent; the disease will progress slowly and can be controlled by medication. Answer: 1 Explanation: 1. ALS is rapidly progressive and fatal, characterized by weakness and wasting of muscles that are under voluntary control, without any accompanying sensory changes. Death usually occurs due to respiratory failure. 2. The prognosis is not good. The quality of life will not be good. 3. A new drug, riluzole (Rilutek), is now available in the treatment of the disease but will not halt it. Death usually occurs due to respiratory failure. 4. The disease is rapidly progressive. A new drug, riluzole (Rilutek), is now available to treat the disease but will not halt it. Death usually occurs due to respiratory failure. Page Ref: 1655 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

9 ..

10) A patient is diagnosed with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the priority nursing activity for this patient? 1. Support the patient and family to meet physical and psychosocial needs. 2. Monitor for infection. 3. Assist the patient to avoid complications. 4. Assist the patient to adapt to the disease. Answer: 1 Explanation: 1. Support for the patient and family should receive the highest priority for nursing intervention. 2. It is also important to monitor for infection, but not as important as supporting the patient and family to meet physical and psychosocial needs. 3. It is also important to assist the patient and family to avoid complications, but not as important as supporting the patient and family to meet physical and psychosocial needs. 4. It is also important to assist the patient and family to adapt to the disease, but not as important as supporting the patient and family to meet physical and psychosocial needs. Page Ref: 1656 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Practice-Know-How; Apply evidence to support decision making in situations characterized by ambiguity and uncertainty | Nursing/Integrated Concepts: Nursing Process: Implementation/Caring Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

10 ..

11) A patient with Guillain-Barré syndrome asks if recovery is possible. What should the nurse respond to this patient? 1. "Recovery will be slow, but your chance of getting better is good." 2. "Only time and prayer will tell." 3. "Do not worry about that right now." 4. "Recovery is not likely." Answer: 1 Explanation: 1. Recovery is likely, but it can take weeks to years for recovery. 2. Nontherapeutic responses do not address the patient's concerns. 3. Nontherapeutic responses do not address the patient's concerns. 4. Recovery is likely, but it can take weeks to years for recovery. Page Ref: 1661 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Sensory/Perceptual Alterations Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with neurologic disorders.

11 ..

12) The nurse is assessing a patient with Guillain-Barré syndrome. What should the nurse expect to assess in this patient? Select all that apply. 1. Increased muscular weakness 2. Increased lower extremity edema 3. Increased confusion 4. Increased intolerance to light 5. Decreased deep tendon reflexes Answer: 1, 5 Explanation: 1. As Guillain-Barré develops, the patient will experience muscle weakness with paralysis from altered nerve conduction (motor nerves become demyelinated). 2. Increased lower extremity edema is not a manifestation of this disorder. 3. Confusion is not a manifestation of this disorder. 4. Intolerance to light is not a manifestation of this disorder. 5. One manifestation of the acute stage is decreased deep tendon reflexes. Page Ref: 1661 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

12 ..

13) A 30-year-old nurse who works on a busy medical-surgical unit has been diagnosed with multiple sclerosis (MS). What should the nurse identify as a priority for self-care? 1. Apply for nursing positions that are less stressful and demanding. 2. Work as hard as possible now because it may not be possible later. 3. Continue to work as scheduled without making changes. 4. Leave employment as a nurse due to the need for complete bed rest. Answer: 1 Explanation: 1. Multiple sclerosis (MS) is progressive and will be negatively affected by working long hours and enduring stressful shifts. It is important for this patient to plan a schedule that is less demanding and move now to a work environment that is less stressful for adapting to life with MS. 2. There is no way of knowing how the disease will progress in this person. 3. Maintaining a routine schedule might be difficult because of fatigue. 4. There is no reason for the nurse to quit working because complete bed rest is not indicated. Page Ref: 1645 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

13 ..

14) The nurse is reviewing medication orders for a patient with multiple sclerosis (MS). What medication should the nurse expect to be prescribed for this patient? 1. Dexamethasone (Decadron) 2. Meperidine (Demerol) 3. Monoamine oxidase (MAO) inhibitors 4. Rivastigmine tartrate (Exelon) Answer: 1 Explanation: 1. Dexamethasone (Decadron) decreases inflammation and suppresses the immune system. 2. Meperidine (Demerol) is a narcotic analgesic and would not be used to treat MS. 3. MAO inhibitors are used to treat depression. 4. Rivastigmine tartrate (Exelon) is used in the treatment of Alzheimer disease. Page Ref: 1643 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.

14 ..

15) A patient is suspected of having myasthenia gravis (MG). Which test should the nurse expect to be used to improve this patient's strength for about five minutes? 1. Tensilon test 2. Computed tomography (CT) scan of the legs 3. Nerve stimulation study 4. Analysis of anti-acetylcholine receptor antibodies Answer: 1 Explanation: 1. The Tensilon test produces a five-minute increase in muscle strength. 2. A computed tomography (CT) scan of the legs is not indicated for this patient. 3. The nerve stimulation study can be done to help diagnose MG, but does not require a drug injection. 4. The analysis of anti-acetylcholine receptor antibodies can be done to help diagnose MG, but does not require a drug injection. Page Ref: 1658 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.

15 ..

16) The nurse is assessing a patient with myasthenia gravis. Which is a characteristic of this disease? Select all that apply. 1. Routine exercise provides an improvement in muscle strength. 2. Visual problems may be an early symptom. 3. There may be difficulty swallowing. 4. Great improvement occurs in muscle strength with physical therapy. 5. There may be poor articulation in speaking. Answer: 2, 3, 5 Explanation: 1. Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength, exercise tends to fatigue muscles. 2. The manifestations of myasthenia gravis correspond to the muscles involved. Initially, the eye muscles are affected and the patient experiences either diplopia (unilateral or bilateral double vision) or ptosis (drooping of the eyelid). 3. Patients may have periods of dysphagia (difficulty swallowing) and dysarthria (problems with speech). 4. Although treatments such as glucocorticoid and immunosuppressant therapy may result in an increase in muscle strength, exercise tends to fatigue muscles, while rest will improve function. 5. The voice is weak with a muffled nasal quality. Page Ref: 1658 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

16 ..

17) A patient experiencing blurred vision and muscle spasms that occur over the past several months is scheduled for an MRI and lumbar puncture with examination of the CSF. Which important patient history information is important for the nurse to note? Select all that apply. 1. The patient is a 22-year-old woman from Canada. 2. The patient is Caucasian and lives in the United States. 3. The patient has a family history of epilepsy. 4. The patient has been depressed. 5. The patient's father had Parkinson disease. Answer: 1, 2 Explanation: 1. Women are affected by MS two times more often than men. Onset is typically between the ages of 20 and 40. 2. High rates of multiple sclerosis occur in regions of northern Europe, the United States, and Canada. 3. Family history of epilepsy is an important item of the patient's history but does not support a diagnosis of MS. 4. Family history of Parkinson disease is an important item of the patient's history but does not support a diagnosis of MS. 5. Family history of depression is an important item of the patient's history but does not support a diagnosis of MS. Page Ref: 1638 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

17 ..

18) A patient's spouse states, "I've noticed that my spouse doesn't sleep well anymore and sometimes can't find the right words." What is the most appropriate response by the nurse? 1. "How long have you noticed these changes?" 2. "Does anyone in your family have Alzheimer disease?" 3. "These are common changes associated with age." 4. "Do you think your spouse is depressed?" Answer: 1 Explanation: 1. Many older adults experience mild problems with memory, but do not have AD. Careful evaluation of the older adult is done in order to avoid misdiagnosing dementia in these cases. 2. Family history is important to note, but a diagnosis of Alzheimer disease is made by eliminating all physiological factors first. 3. Assuming these are normal age-related changes is inappropriate. 4. Although depression is underdiagnosed in the elderly patient and is sometimes mistaken for Alzheimer disease, a thorough evaluation must be made before making a diagnosis. Page Ref: 1632 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

18 ..

19) The nurse visits a stage 5 Alzheimer disease patient who lives at home with a spouse. In order to meet the needs of the spouse, what should the nurse suggest? 1. Finding respite care to come into the home several days a week 2. Making arrangements for the patient to visit the local senior citizens' center in the afternoon 3. Providing the patient a list of daily activities to complete 4. Finding placement in a long-term care facility Answer: 1 Explanation: 1. Stage 5 patients generally exhibit decreased capacity to perform complex tasks (such as buying groceries or paying bills), a reduced memory for personal history, and are often unable to carry out activities of daily living. The spouse needs opportunities to have breaks from the demands of the patient's care. Since the stage 5 patient does not adapt well to changes in the environment, it would be best to have someone come into the home, rather than to have the patient go out. 2. An outing would be better suited for the patient in stage 1. 3. A list of activities would be better suited for the patient in stage 1. 4. Recommending placement in long-term care might be premature and is not up to the nurse. Page Ref: 1632, 1636 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Support Systems Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

19 ..

20) A patient complains of periods of confusion and forgetfulness at times, and reports clear thought process at most times of the day. The symptoms have been gradually worsening. What should the nurse say in response to this patient? 1. "Have you started any new medications since the symptoms began?" 2. "You probably have nothing to worry about; it's most likely stress-related." 3. "Everybody has a few problems with memory as they get older." 4. "You should probably have an MRI of your brain." Answer: 1 Explanation: 1. The diagnosis of Alzheimer disease requires the documented presence of dementia, onset between 40 and 90 years, no loss of consciousness, and absence of systemic or brain disorders that could cause mental changes. Side effects of medication should also be ruled out as a possible cause of the symptoms. 2. A nurse should never discount the patient's concerns and memory loss with confusion. 3. Forgetfulness is not part of the normal aging process. 4. The nurse needs to explore further before an expensive diagnostic study is considered. It would be beyond the scope of practice for the nurse to recommend this testing. Page Ref: 1632 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

20 ..

21) A patient with Parkinson disease asks the nurse what an "on-off" problem means with medications. What should the nurse explain to the patient? 1. "The 'on' times will be when your symptoms are under control; the 'off' times are when you will have increased problems with symptom management." 2. "There will be times when you are depressed (off) and when you are happy (on)." 3. "You will have to take breaks from this medicine by stopping (off) and starting it (on) again, so you don't build up a tolerance to it." 4. "I'm not a pharmacist, so I shouldn't be answering this question." Answer: 1 Explanation: 1. The "on-off" phenomenon occurs after the patient takes levodopa for several years; this phenomenon is characterized by unexpected dyskinesias (abnormal movements) and lack of symptom control. 2. The "on-off" phenomenon has nothing to do with depressive episodes. 3. The medication for Parkinson disease should not be started and stopped. 4. A nurse should be able to answer questions about the patient's medications, or at least attempt to find the answer if it is not known. Page Ref: 1650 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

21 ..

22) A patient with myasthenia gravis is prescribed pyridostigmine (Mestinon). When teaching about this medication, what should the nurse teach the patient to immediately report? Select all that apply. 1. Increased weakness 2. Problems with increased drooling 3. Orthostatic hypotension 4. Headache 5. Increased difficulty swallowing Answer: 1, 2, 3, 5 Explanation: 1. An overdose or underdose of anticholinesterase drugs can lead to a myasthenic or cholinergic crisis. The goal of pharmacological therapy is to increase muscle tone; weakness after taking the medication should be reported as soon as possible to offset a medical emergency. 2. Increased drooling is a common side effect of pyridostigmine (Mestinon) but should be reported. 3. Lowering of blood pressure is a common side effect of pyridostigmine (Mestinon) but should be reported immediately. 4. Headache is not a side effect of pyridostigmine (Mestinon) that needs to be reported. 5. Manifestations of myasthenic crisis include increased difficulty swallowing and chewing, muscle weakness, fast heartbeat, and restlessness. Page Ref: 1659 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

22 ..

23) A patient with stage 2 Alzheimer disease becomes very agitated in the evenings. What would be an appropriate intervention for the nurse to use for this patient? 1. Playing soft music in the patient's room 2. Using anti-anxiety medications or tranquilizers 3. Moving the patient to an area of activity to provide distraction 4. Recommending the patient be moved to a more secure environment Answer: 1 Explanation: 1. The use of music is considered an alternative therapy that is helpful in the treatment of Alzheimer disease. 2. Although the use of anti-anxiety agents and tranquilizers might be helpful, this is not a true nursing intervention. 3. Patients with Alzheimer disease should be removed from situations that are causing increased anxiety, such as noisy activities involving large groups. High-stimulus situations may increase anxious feelings and agitation. 4. If the patient were not a danger to him- or herself or others, there would be no indication that a more secure environment would be the best intervention. Page Ref: 1632, 1633 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

23 ..

24) The spouse of a patient with Alzheimer disease (AD) asks what sundowning means. How should the nurse respond to this question? 1. "It causes agitation, disorientation to time, and wandering during the afternoon or early evening." 2. "The eyes will appear more downcast and the lids will droop." 3. "Repetition of words or phrases occurs more frequently." 4. "The ability to perform simple tasks is lost." Answer: 1 Explanation: 1. Sundowning can be decreased by providing quiet activities, such as listening to favorite music in the afternoon or early evening. 2. Downcast eyes and drooping eyelids is not a description of sundowning. 3. Echolalia is the term for frequent repetition of words or phrases. 4. Loss of the ability to perform simple tasks is common to stage 2 of AD. Page Ref: 1635 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with neurologic disorders.

24 ..

25) The nurse is completing discharge teaching to a patient with a new diagnosis of multiple sclerosis (MS). What does the nurse recommend about diet? 1. Focus on maintaining a weight as close as possible to what is recommended for the patient's height and weight. 2. Increase fats and lower carbohydrates. 3. Include foods that are easy to swallow since dysphagia is a problem seen in the early stages of the disease. 4. Basically remain the same, as there are no nutritional changes in the MS patient. Answer: 1 Explanation: 1. It is recommended that the MS patient should ideally maintain a weight as close as possible to what is recommended for the patient's height and weight. 2. There is no reason for the patient to increase fat intake and decrease carbohydrates. 3. Dysphagia is seen in the later stages of the disease. 4. Dysphagia is a common problem as MS progresses. At that point, the diet should be adapted to accommodate changes in the patient's ability to chew and swallow, and collaboration with a dietitian will be important. Page Ref: 1643 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

25 ..

26) The nurse suspects that a patient has Parkinson disease (PD). What did the nurse assess as early signs of this neurologic disease? Select all that apply. 1. Fatigue 2. Cogwheel rigidity 3. Being "frozen" 4. Bilateral involvement 5. A slight rhythmic hand tremor Answer: 1, 5 Explanation: 1. PD begins with subtle manifestations. Patients may complain of feeling tired and may move more slowly. 2. Cogwheel rigidity is a later manifestation of PD. 3. Being "frozen" is a later manifestation of PD. 4. Bilateral involvement is a later manifestation of PD. 5. Tremor at rest is usually the first manifestation experienced in PD. Page Ref: 1647 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

26 ..

27) The nurse is completing teaching to a patient with a new diagnosis of Bell palsy. What should be a priority focus of this teaching? 1. Eye care 2. Promoting effective swallowing 3. Pain management 4. Improving muscle strength in the upper extremity Answer: 1 Explanation: 1. Eye care should be addressed since manifestations of Bell palsy include paralysis of the upper eyelid with loss of the corneal reflex and increased tearing on the affected side. 2. Chewing, not swallowing, may be difficult due to unilateral paralysis of facial muscles. 3. Pain may precede the onset of facial paralysis but is not an issue during the course of the disease. 4. Upper extremity muscles are not affected. Page Ref: 1666 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with neurologic disorders.

27 ..

28) The nurse is caring for a patient with trigeminal neuralgia. What should the nurse expect the treatment focus to be for this health problem? 1. Drugs such as tricyclic anticonvulsants or rhizotomy 2. Antiviral drugs such as acyclovir and physical therapy 3. Respiratory support and NSAIDs 4. Physical therapy and warm, moist packs to the affected area Answer: 1 Explanation: 1. Trigeminal neuralgia is treated by a pharmacologic approach to pain control by prescribing tricyclic anticonvulsants such as carbamazepine (Tegretol) or rhizotomy, which is surgically severing the nerve root. 2. Antiviral drugs and physical therapy are the treatments for Bell palsy. 3. Respiratory support and NSAIDs are not appropriate treatments. 4. Physical therapy and warm, moist packs to the affected area are not appropriate treatments. Page Ref: 1664 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.3 Describe the pathophysiology and manifestations of cranial nerve disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.

28 ..

29) The nurse is caring for a patient with amyotrophic lateral sclerosis (ALS). What should the nurse identify as being the primary focus of care for this patient? 1. Respiratory support as the muscles of breathing fail, and managing secretions due to the inability to swallow and communication 2. Providing gastrostomy feedings as soon as possible so as to build up muscle mass when motor functions return 3. Pain management and active range-of-motion (ROM) exercises 4. Giving immunosuppressants Answer: 1 Explanation: 1. Manifestations of ALS include loss of both upper and motor neurons resulting in loss of the muscles of respiration and swallowing. Atrophy of the tongue and facial muscles results in swallowing difficulty and the inability to communicate. 2. Gastrostomy feedings may be needed as the disorder progresses and muscle function is permanently lost. 3. Pain management is not part of the treatment of ALS. Active ROM exercises are instituted only if the patient is able, then passive ROM exercises are initiated to stimulate circulation. 4. Immunosuppressants are not part of the treatment of ALS. Page Ref: 1656 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with neurologic disorders.

29 ..

30) The nurse is caring for a patient with Guillain-Barré syndrome. Which medication should the nurse expect to provide to this patient? Select all that apply. 1. Antibiotics for urinary tract or respiratory infections 2. Morphine for muscle pain 3. Anticoagulants to prevent DVTs and pulmonary emboli 4. Anticonvulsants to prevent seizures 5. Anticholinesterase inhibitors to improve muscle strength Answer: 2, 3 Explanation: 1. Medications may be prescribed to provide support or prophylaxis, or to combat concurrent problems in the patient with Guillain-Barré syndrome. Antibiotics are not routinely administered. 2. Medications may be prescribed to provide support or prophylaxis, or to combat concurrent problems in the patient with Guillain-Barré syndrome. These include morphine for muscle pain. 3. Medications may be prescribed to provide support or prophylaxis, or to combat concurrent problems in the patient with Guillain-Barré syndrome. These include anticoagulants to prevent DVTs and pulmonary emboli. 4. Anticonvulsants are not used in the treatment of Guillain-Barré syndrome. 5. Anticholinesterase inhibitors are not used in the treatment of Guillain-Barré syndrome. Page Ref: 1661 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 44.2 Describe the pathophysiology and manifestations of peripheral nervous system disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with neurologic disorders.

30 ..

31) During an assessment, the nurse becomes concerned that a patient is demonstrating early manifestations of amyotrophic lateral sclerosis. What findings did the nurse use to make this clinical determination? Select all that apply. 1. Foot drop 2. Slurred speech 3. Weak hip flexor muscles 4. Bilateral weak hand grasps 5. Fine muscle fasciculations of the hands Answer: 2, 4, 5 Explanation: 1. Foot drop may or may not be a manifestation of amyotrophic lateral sclerosis. 2. Slurred speech is a common early manifestation of amyotrophic lateral sclerosis. 3. Weak hip flexor muscles may or may not be a manifestation of amyotrophic lateral sclerosis. 4. Weakness in an extremity is a common early manifestation of amyotrophic lateral sclerosis. With the loss of muscle innervation, the muscles atrophy, and paralysis results. Muscle mass decreases, and patients complain of progressive fatigue. Typically, the disease first affects the hands. 5. Muscle twitching is a common early manifestation of amyotrophic lateral sclerosis. Fasciculations of involved muscles are common in the early stage of the disorder. Page Ref: 1655 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 44.1 Describe the pathophysiology and manifestations of degenerative neurologic disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with neurologic disorders.

31 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 45 Assessing the Eye and Ear 1) A patient recovering from a stroke is reporting vision changes. For which reason should the nurse consider these changes are occurring? 1. The stroke occurred in the optic region of the patient's brain. 2. The brain interprets information received through the eyes. 3. The patient is experiencing another stroke. 4. The patient is unable to talk because of the stroke. Answer: 2 Explanation: 1. The information provided is inadequate to determine the location of the infarct. 2. The primary functions of the eye are to encode the patterns of light from the environment through photoreceptors and to carry the coded information from the eyes to the brain. The brain gives meaning to the coded information, and interprets what is seen. 3. The patient's clinical manifestations are not consistent with another stroke. 4. There is no indication of the patient's verbal abilities. Page Ref: 1673 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

1 ..

2) While exiting a burning building, a patient's eyebrows and lashes were burned. What should the nurse suspect this patient might experience? 1. Wound infections 2. Fluid and electrolyte imbalance 3. Foreign bodies in the eyes 4. Itchiness as the hair grows back Answer: 3 Explanation: 1. The lack of eyelashes and eyebrows would not increase the patient's risk of developing a wound infection. 2. The lack of eyelashes and eyebrows would not lead to fluid and electrolyte imbalance. 3. The eyebrows shade the eyes and prevent perspiration from entering the eyes. When stimulated, the eyelashes cause the blink reflex, which serves to protect the eyes from foreign bodies. 4. Some discomfort might be experienced as the hair grows back, but this is a minor concern compared to another possibility. Page Ref: 1673 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

2 ..

3) A patient has sustained an injury to the inner layer of the left retina. Which change should the patient expect to experience? 1. Tear production 2. Blinking 3. Reading 4. Peripheral vision and color perception Answer: 4 Explanation: 1. Tear production is not controlled by the inner retina. 2. Blinking is not controlled by the inner retina. 3. Reading will still be possible with this type of injury. 4. The retina is the innermost lining of the eyeball. It has a pigmented outer layer and an inner neural layer. The transparent inner layer is made up of millions of light receptors in structures called rods and cones. Rods enable vision in dim light as well as peripheral vision. Cones enable vision in bright light and the perception of color. Page Ref: 1674-1675 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

3 ..

4) A patient with an injury to the right eye has received an eye patch. Which difficulty might the patient experience because of the patch? 1. Depth perception 2. Reading 3. Light perception 4. Color perception Answer: 1 Explanation: 1. Depth perception depends on visual input from two eyes that function well. 2. Reading may be contraindicated if the treatment plan warns against moving the eyes. 3. Light will still be discernible to the "good" eye. 4. Color will still be discernible to the "good" eye. Page Ref: 1676 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.1 Describe the anatomy, physiology, and functions of the eye, and identify abnormal findings that may indicate visual impairment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

4 ..

5) During an eye examination, a patient is able to read all the letters on the Snellen chart without difficulty at a distance of 15 feet. How should the nurse interpret this finding? 1. Normal 20/20 vision 2. Normal reading vision 3. Visual impairments 4. Normal pupillary reflex Answer: 3 Explanation: 1. For people with normal vision, the distance from the viewed object at which the eyes require no accommodation is 20 feet. 2. This test is not used to assess reading vision. 3. The patient must stand closer than normal to read the chart. For people with normal vision, the distance from the viewed object at which the eyes require no accommodation is 20 feet. 4. This test is not used to assess pupillary reflex. Page Ref: 1678 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

5 ..

6) A patient is found to need corrective lenses. Which diagnostic test was most likely used to determine this finding? 1. Computed tomography (CT) scan 2. Tonometry 3. Refractometry 4. Response to atropine eye drops Answer: 3 Explanation: 1. A computed tomography (CT) scan is used to assess structures. 2. Tonometry is used to assess ocular pressure. 3. Refractive errors, with prescription for corrective lenses, are evaluated by retinoscopy and/or refractometry. Pupils must be dilated for accurate diagnosis. 4. The patient's response to atropine drops would not be used to evaluate the need for corrective lenses. Page Ref: 1682 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.3 Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the eye and ear.

6 ..

7) The nurse is assessing a patient's visual fields by covering the right eye with an opaque covering. Which action should the nurse perform next? 1. Cover own right eye. 2. Cover own left eye. 3. Keep both eyes uncovered. 4. Turn the lights on in the room before conducting this examination. Answer: 2 Explanation: 1. This action will not help assess the patient's visual fields. 2. The nurse asks the patient to cover one eye with the opaque cover while the nurse covers his or her own eye opposite the patient's. For example, if the patient covers the right eye, the nurse should cover the left eye. The nurse must have normal fields of vision to perform this examination. 3. This action will not help assess the patient's visual fields. 4. Turning on the lights will not help assess the patient's visual fields. Page Ref: 1678 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.

7 ..

8) A 20-year-old patient is experiencing difficulty with near vision. How should the nurse interpret this finding? 1. Consistent with the aging process 2. Normal in a 20-year-old patient 3. Evidence of presbyopia 4. Evidence of hyperopia Answer: 4 Explanation: 1. Changes in near vision, especially in patients over 45, can indicate presbyopia, which is impaired near vision that results from a loss of elasticity of the lens related to aging. 2. This is not a normal finding in a 20-year-old. 3. Changes in near vision, especially in patients over 45, can indicate presbyopia, which is impaired near vision that results from a loss of elasticity of the lens related to aging. 4. Changes in near vision in younger patients is referred to as hyperopia or farsightedness. Page Ref: 1678 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

8 ..

9) When performing the cover test, the nurse notes that a patient's left eye deviates inward when focusing on an object. What should this finding indicate to the nurse? 1. Presbyopia 2. Hyperopia 3. Weakness 4. Myopia Answer: 3 Explanation: 1. Presbyopia is impaired near vision resulting from a loss of elasticity of the lens related to aging. 2. Presbyopia is impaired near vision resulting from a loss of elasticity of the lens related to aging. In younger patients, this condition is referred to as hyperopia (farsightedness). 3. The movement of an eye with the cover test indicates weakness of the eye muscles. 4. Myopia is the term for nearsightedness. Page Ref: 1678 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

9 ..

10) A patient who is using atropine eyedrops is found to have a poor consensual light response. What should the nurse conclude from this finding? 1. An abnormal finding that should be reported to the healthcare provider 2. Normal because of the eyedrops 3. Evidence of retinal degeneration 4. Evidence of optic nerve damage Answer: 2 Explanation: 1. This is a normal response and does not need to be reported to the physician. 2. Some eye medications may cause unequal dilation, constriction, or inequality of pupil size. Morphine and narcotic drugs may cause small, unresponsive pupils, and anticholinergic drugs such as atropine may cause dilated, unresponsive pupils. 3. Retinal degeneration is evidenced by inability of the pupils to respond appropriately to light. 4. Damage to the optic nerve would likely produce visual disturbances. Page Ref: 1679 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

10 ..

11) During the assessment of a patient's outer eyes, the nurse suspects that the patient has a hair follicle infection. What did the nurse most likely assess in this patient? 1. Xanthelasma 2. Ptosis 3. Exophthalmos 4. Sty Answer: 4 Explanation: 1. Yellow plaques noted most often on the lid margins are referred to as xanthelasma and have cosmetic significance only. 2. Ptosis, or drooping of the eyelid, may be congenital or may be associated with stroke or neuromuscular disorders. 3. Exophthalmos is an abnormal prominence of the eye and is associated with thyroid disease. 4. An acute localized inflammation of a hair follicle is known as a hordeolum or a sty and is generally caused by staphylococcal organisms. Page Ref: 1679 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

11 ..

12) A patient is assessed as having an absence of the fovea centralis. Which should be inspected next? 1. Red reflex 2. Retina 3. Macula 4. Optic disc Answer: 3 Explanation: 1. The red reflex should be visible when using the ophthalmoscope if it is properly positioned. It is not related to the absence of the fovea centralis. 2. Inspection of the retina would not provide any further information concerning the absent fovea centralis. 3. Absence of the fovea centralis is common in older patients. It may indicate macular degeneration, a cause of loss of central vision. During the inspection of the macula, the macula should be visible on the temporal side of the optic disc. 4. Inspection of the optic disc would not provide any further information concerning the absent fovea centralis. Page Ref: 1680 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

12 ..

13) A patient with a sore throat is complaining of "trouble with hearing." What might the patient be experiencing? 1. Sinus infection 2. Middle ear infection 3. Infected tonsils 4. Inner ear infection Answer: 2 Explanation: 1. The manifestations of a sinus infection would not include auditory compromise. 2. The mucous membrane lining the middle ear is continuous with the mucous membranes lining the pharynx. 3. The manifestations of tonsillitis would not include auditory compromise. 4. The inner ear is not implicated in this scenario. Page Ref: 1683 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.3 Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

13 ..

14) During a Weber test, a patient is found to have increased hearing in the right ear. What should the nurse suspect is occurring with this patient? 1. Normal aging 2. Conductive hearing loss in the right ear 3. Possible buildup of cerumen or otitis media in the left ear 4. Perforated left eardrum Answer: 2 Explanation: 1. Lateralization is not associated with normal aging. 2. The sound will be louder on the impaired side with a conductive hearing loss; in this case, the right ear. 3. A buildup of cerumen or an infection such as otitis media can cause conductive hearing loss. If this were the case, the patient would have a buildup of cerumen or otitis media in the right ear. 4. Perforation of the eardrum can cause conductive hearing loss. If this were the case, the patient would have a perforated eardrum of the right ear. Page Ref: 1686 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

14 ..

15) A patient is found to have small, raised lesions on the rim of the ear. Which health problem should the nurse suspect is occurring with the patient? 1. Hypertension 2. Gout 3. Heart disease 4. Kidney failure Answer: 2 Explanation: 1. These lesions are not associated with hypertension. 2. Small, raised lesions on the rim of the ear are known as tophi and may indicate gout. Tophi are the result of uric acid crystal buildup. 3. These lesions are not associated with heart disease. 4. These lesions are not associated with kidney failure. Page Ref: 1687 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

15 ..

16) An older patient says, "I seem to be talking so much louder these days and I don't know why!" What should the nurse realize this patient might be experiencing? 1. Loss of hair cells in the middle ear 2. Cochlear atrophy 3. Impacted cerumen 4. Stiffening of the middle ear structures Answer: 4 Explanation: 1. Loss of hair cells in the middle ear would not produce the perception that the patient is speaking more loudly. 2. Cochlear atrophy would not produce the perception that the patient is speaking more loudly. 3. Impacted cerumen would not produce the perception that the patient is speaking more loudly. 4. One age-related change of the middle ear is the weakening and stiffening of muscles and ligaments, which decreases the acoustic reflex. Sounds made from one's own body and speech are louder and may further interfere with hearing, speech, and communication. Page Ref: 1689 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

16 ..

17) A patient is scheduled for diagnostic tests to determine the cause of a hearing and balance disorder. For which diagnostic test should the nurse prepare this patient? Select all that apply. 1. Tonometry 2. Computed tomography (CT) scan 3. Electronystagmography (ENG) 4. Auditory evoked potentials (AEP) 5. Auditory brainstem response (ABR) Answer: 3, 4, 5 Explanation: 1. Tonometry is used to measure intraocular pressures. 2. CT scan would note abnormalities in organ structure but would not be helpful in identifying hearing and balance issues. 3. Electronystagmography (ENG) is used to detect eye movements (nystagmus) in response to changes in head position or stimulation of balance sensors in the inner ear using warm and cool water or air. It may be used to evaluate vertigo or help diagnose Ménière disease. 4. The auditory evoked potential test is a diagnostic test used to help determine hearing and balance disorders. 5. The auditory brainstem response test is a diagnostic test used to help determine hearing and balance disorders. Page Ref: 1688 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the eye and ear.

17 ..

18) The nurse is preparing to perform an otoscopic examination of the ear. List in order of priority the steps the nurse would perform. Choice 1. Explain the procedure to the patient. Choice 2. Grasp the superior portion of the auricle and pull up, out, and back to straighten the auditory canal. Choice 3. Hold the handle of the otoscope in the dominant hand, otoscope handle upward. Choice 4. Wash the hands. Choice 5. Turn on the otoscope light. Choice 6. Rest the hand holding the otoscope against the patient's head. Answer: 1, 4, 5, 3, 6, 2 Explanation: Choice 1. The nurse should first explain the procedure to the patient. Choice 2. The last step is to grasp the superior portion of the auricle and pull up, out, and back to straighten the auditory canal. Choice 3. The fourth step is to hold the handle of the otoscope in the dominant hand with the otoscope handle upward. Choice 4. The second step is to wash the hands. Choice 5. The third step is to prepare to use the otoscope. Choice 6. The fifth step is to rest the hand holding the otoscope on the patient's head. Page Ref: 1685-1686 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.

18 ..

19) A patient is experiencing dizziness and disequilibrium with head movements. For which problem should the nurse plan care? 1. Imbalanced fluids 2. Difficulty adjusting to life changes 3. Problems with coping 4. Potential to fall Answer: 4 Explanation: 1. Not enough information is given in the question to determine whether the symptoms of dizziness and disequilibrium are due to a fluid imbalance. 2. It is unlikely adjustment difficulties are caused by dizziness and disequilibrium with head movements. 3. It is unlikely that coping problems are caused by dizziness and disequilibrium with head movements. 4. Dizziness and disequilibrium are caused by changes within the vestibule and semicircular canals of the inner ear, which give the sensation of starting, stopping, and head position in relation to gravitational pull. Dizziness and disequilibrium create a risk for potential injury from falling because of loss of balance. Page Ref: 1689 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

19 ..

20) The nurse suspects that a patient has bone-conductive hearing loss. Which assessment technique should the nurse use to differentiate between bone conduction loss and air conduction loss? 1. Rinne test 2. Weber test 3. Assessment of balance and body position 4. Palpation of mastoid process Answer: 1 Explanation: 1. A Rinne test is a hearing test that compares air conduction of sound to bone conduction. In conductive hearing loss, bone conduction is equal to or greater than air conduction. 2. A Weber test identifies hearing loss by lateralization (increase in sound) to the ear with a conductive hearing loss. Thus, this test would be helpful to identify a difference between left and right ear changes that might be related to a conductive hearing loss. 3. Balance and body position changes would reflect a disturbance in the inner ear and possible nerve damage. If balance and body position are affected, this information does not differentiate between conductive hearing loss, nerve loss, and a combination of both types of losses. 4. Palpation of the mastoid process would assess for pain or swelling, which can indicate inflammation of the external auditory canal and mastoid sinuses. Mastoiditis can lead to fluid or scarring within the middle ear, which could interfere with sound conduction from the external to the inner ear. This assessment would be helpful to identify a source for conductive hearing loss. Page Ref: 1686 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.

20 ..

21) A patient has a tonometer test result of 28 mmHg. Which explanation by the nurse about this pressure reading is most accurate? 1. The pressure in the eye has been measured and is too low. Medication will be required to increase the pressure and prevent blindness from retinal damage. 2. The pressure in the inner ear has been measured to evaluate the semicircular canals' function related to nerve damage and is within the normal range. 3. The pressure in the middle ear that builds up with mastoiditis has been measured. The condition needs to be treated with surgical insertion of tubes to drain the fluid behind the tympanic membrane. 4. The pressure in the eye has been measured and is above normal. This condition could lead to possible retinal changes if not treated. Answer: 4 Explanation: 1. A measurement of 28 mmHg is above the normal range of 10-22 mmHg. 2. A tonometer measures eye pressure, not ear pressure. 3. Typanometry is performed to evaluate the response of the tympanic membrane to changes in air pressure and middle ear function. 4. Tonometry is used to diagnose increased intraocular pressure in glaucoma. A handheld tonometer or computerized device may be used. The cornea is anesthetized prior to being touched with the device. The normal range is 10-22 mmHg. Page Ref: 1682 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

21 ..

22) The nurse is assessing a 75-year-old patient. Which patient report would require immediate action by the nurse? 1. Occasional presence of floaters 2. Greater need for additional light and reading glasses 3. Development of a white circle around the iris 4. Frequent falls from tripping over items on the floor Answer: 4 Explanation: 1. Floaters are often seen by older patients and are related to debris or condensation when the vitreous body pulls away from the retina. Unless excessive, with vision suddenly greatly impaired, floaters are not an urgent problem. 2. Near-vision accommodation is gradually lost as elasticity declines and presbyopia (a common problem in older patients) develops with aging. This is not an urgent problem. 3. White circles around the iris of the eye (arcus senilis) are caused by lipid deposits through a gradual process that does not require immediate care. 4. Excessive falling can represent changes in vision sufficient to alter the field of vision. Depth perception changes and adaptation to changes in light represent a need for immediate additional assessments. Page Ref: 1689 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

22 ..

23) The nurse is assessing a patient for neurological changes after a head trauma. Which eye assessment should the nurse perform? Select all that apply. 1. Ptosis 2. Extraocular movements 3. Accommodation 4. Color of iris 5. Nystagmus Answer: 1, 2, 3, 5 Explanation: 1. Ptosis refers to the drooping of one eyelid and may indicate cranial nerve damage. 2. Failure of one or both eyes to follow an object in any given direction may reflect cranial nerve dysfunction. 3. Accommodation is the bending of light rays at the lens so that they focus on one point on the retina. Failure of accommodation, along with lack of pupil response to light, may signal a neurologic problem. 4. The color of the iris does not reflect neurologic changes or deficits in cranial nerves. 5. Nystagmus is the involuntary rhythmic movement of the eyes that occurs with neurologic disorders and the use of some medications. Page Ref: 1678-1679 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.

23 ..

24) The nurse is assessing a patient for a possible conductive hearing loss. What should the nurse perform first? 1. External ear examination 2. Weber test 3. Rinne test 4. Tympanogram Answer: 1 Explanation: 1. Visual inspection of the external ear will give information about possible obstruction by cerumen, drainage, redness, swelling, or objects present in the external canal. Visual inspection can also show the condition of the tympanic membrane (intact or ruptured), swelling, redness, and scarring. Pain also might be identified when using the otoscope to visualize the structures in the external canal. 2. A Weber test is done to identify the equality of sound heard in both ears. This would be the next step in the assessment process. Normally, sound is heard equally in both ears. 3. A Rinne test is done to identify the difference between bone and air conduction of sound by each ear. This is the third step. Normally, sound can be heard twice as long by air conduction as by bone conduction. 4. Tympanograms are done to measure the pressure of the middle ear by evaluating the tympanic membrane's response to waves of pressure. This test would be done last, only if other symptoms were noted or indicated by the nurse's findings. Page Ref: 1687 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.

24 ..

25) The nurse is performing an assessment of an 82-year-old patient's eyes. Which patient statement should the nurse expect based on the patient's age? Select all that apply. 1. "I've been having some drainage from the inside corner of my eye." 2. "My eyes feel so dry most of the time." 3. "I have almost fallen several times at home going down our basement stairs." 4. "I have this white circle around the color of my eyes." 5. "I have a hard time driving at night." Answer: 2, 3, 4, 5 Explanation: 1. Drainage from the puncta may indicate an infectious process and is not a normal age-related change. 2. The lacrimal apparatus within the older patient's eye produces fewer tears. The eyes may look and feel dry. 3. The older patient has an increased risk of falls as a result of changes in depth perception and adaptation to changes in light. 4. A partial or complete white circle may form around the cornea (arcus senilis). 5. With aging, the lens loses elasticity, with reduced ability to change shape and focus light. The lens loses clarity and becomes thicker and increasingly opaque. Page Ref: 1688-1689 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

25 ..

26) The nurse is assessing the ears of a patient who is African American. Which assessment finding should the nurse identify as abnormal? 1. During the Rinne test, the patient hears the sound by air conduction for an equal amount of time as by bone conduction. 2. The patient is able to hear whispers from 18 inches away. 3. The patient's cerumen is dark gray. 4. The patient's tympanic membrane is pearly gray. Answer: 1 Explanation: 1. This patient has some conductive hearing loss. The patient with no conductive hearing loss hears the sound twice as long by air conduction as by bone conduction. 2. The patient should normally be able to hear the nurse whispering from 1 to 2 feet away. 3. People with darker skin tend to have darker cerumen. This is a normal finding. 4. The tympanic membrane should look pearly gray. This is a normal finding. Page Ref: 1686 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

26 ..

27) The nurse is reviewing the physiology of the ear with a patient with a hearing disorder. What should the nurse explain about the function of the inner ear? Select all that apply. 1. It coordinates visual pathways. 2. It integrates efferent neuron messages. 3. It provides information about head position. 4. It maintains middle ear structure and function. 5. It conducts sound. Answer: 3, 5 Explanation: 1. The inner ear is not involved with visual pathways. 2. The inner ear does not integrate efferent neuron messages. 3. Receptors within the inner ear maintain equilibrium by responding to changes in head position in order to coordinate body movements and balance. 4. The inner ear does not maintain middle ear structure and function. 5. The inner ear is a maze of bony chambers. The membranous labyrinth, a delicate network of interconnected fluid-filled tubes, lies within this maze. Perilymph, a fluid similar to cerebrospinal fluid, flows between the bony and the membranous labyrinth. Within the chambers of the membranous labyrinth is a fluid called endolymph. These fluids conduct sound vibrations. Page Ref: 1683 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 45.3 Describe the anatomy, physiology, and functions of the ear, and identify abnormal findings that may indicate hearing impairment. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

27 ..

28) The nurse is preparing to assess an older patient's ears. Which technique should the nurse consider when conducting this assessment? Select all that apply. 1. Whisper test 2. Rinne test 3. Weber test 4. Electronystagmography (ENG) 5. Audiometer Answer: 1, 2, 3, 5 Explanation: 1. The examiner can whisper a word 1 or 2 feet behind the patient, asking the patient to repeat the word; this may provide a rough estimate of hearing acuity. 2. The Rinne test measures hearing loss. 3. The Weber test measures hearing loss. 4. Electronystagmography (ENG) is used to detect eye movements (nystagmus) in response to changes in head position or stimulation of balance sensors in the inner ear using warm and cool water or air. It may be used to evaluate vertigo or help diagnose Ménière disease. 5. Audiometry is used to evaluate and diagnose conductive and sensorineural hearing loss. Page Ref: 1686-1687 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the eye and ear.

28 ..

29) The nurse determines that an older patient has age-related changes in the vestibular structures of the ear. What should the nurse identify as a risk for this patient? Select all that apply. 1. Infection 2. Falls 3. Medication errors 4. Food intolerance 5. Problems communicating Answer: 2, 5 Explanation: 1. Infection is unrelated to vestibular changes. 2. Degeneration and atrophy of inner ear structures involved in balance and equilibrium increase the risk for falls. 3. Medication errors are unrelated to vestibular changes. 4. Food intolerance is unrelated to vestibular changes. 5. With the loss of high-frequency sounds, speech may be distorted, contributing to a risk for problems with communication. Page Ref: 1689 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 45.5 Differentiate considerations for assessing vision and hearing of older adults, veterans, and adults with sequelae of childhood/congenital conditions. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

29 ..

30) A patient has a tonometry measurement of 29 mmHg. What additional assessment finding should the nurse identify that indicates this patient has glaucoma? Select all that apply. 1. Narrowing visual fields 2. Loss of definition of the optic disc 3. Areas of hemorrhage, exudate, and white patches 4. Narrowing of the vein where an arteriole crosses over 5. Displaced blood vessels from the center of the optic disc Answer: 1, 5 Explanation: 1. Narrowing of visual fields may indicate an eye disorder such as glaucoma. 2. Loss of definition of the optic disc is seen in papilledema from increased intracranial pressure. 3. Areas of hemorrhage, exudate, and white patches may be a result of diabetes or longstanding hypertension. 4. Hypertension may cause a narrowing of the vein where an arteriole crosses over. 5. Glaucoma may cause displacement of blood vessels from the center of the optic disc due to increased intraocular pressure. Page Ref: 1678, 1680 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

30 ..

31) The nurse is assessing a patient with retinitis pigmentosa. Which finding should the nurse identify as consistent with this health problem? Select all that apply. 1. Loss of visual acuity 2. Loss of peripheral vision 3. Progressive night blindness 4. One dilated, unresponsive pupil 5. Reduced perception of blue-green tones Answer: 1, 2, 3 Explanation: 1. Retinitis pigmentosa results in loss of visual acuity. 2. Retinitis pigmentosa results in loss of peripheral vision. 3. Retinitis pigmentosa results in progressive night blindness. 4. A patient who has one dilated and unresponsive pupil may have paralysis of the oculomotor nerve. 5. A change in blue-green perception is an age-related change caused by the atrophy of photoreceptor cells in the eyes. Page Ref: 1677 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

31 ..

32) During a health history interview, the nurse becomes concerned that a patient is at risk for a genetic hearing disorder. On what information did the nurse base this clinical decision? Select all that apply. 1. The patient's mother, age 76, uses hearing aids. 2. The patient's father had tubes in the ears as a child. 3. The patient's brother lost his hearing because of a thyroid disorder. 4. The patient's sister was treated for ear drainage after swimming. 5. The patient's nephew had surgery to remove a tumor on the acoustic nerve. Answer: 1, 3, 5 Explanation: 1. Hereditary hearing impairment (HHI) is believed to account for more than 50% of childhood hearing loss and can also manifest later in life. Most HHI follows an autosomal recessive inheritance pattern. Heredity is also increasingly recognized as a contributor to presbycusis. 2. Tubes in the ears may have been used to treat ear infections. This does not increase the patient's risk for a genetic hearing loss. 3. Pendred syndrome is an inherited disorder that accounts for as much as 10% of hereditary deafness. The deafness is usually accompanied by a thyroid goiter. 4. Ear drainage is an indication of infection. This does not increase the patient's risk for a genetic hearing loss. 5. Neurofibromatosis, a rare inherited disorder, is characterized by the development of acoustic neuromas, or benign tumors of the auditory nerve. Page Ref: 1685 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.4 Outline the components of the assessment of the ear and hearing, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

32 ..

33) During an assessment the nurse suspects that a victim of a motor vehicle crash is a narcotic substance user. Which assessment finding would confirm the nurse's suspicion? Select all that apply. 1. Small pupils 2. Dilated pupils 3. Unequal pupil size 4. Poor pupillary response to light 5. One dilated and unresponsive pupil Answer: 1, 4 Explanation: 1. The use of morphine and narcotic drugs may cause small pupils. 2. The use of anticholinergic drugs such as atropine may cause dilated pupils. 3. Pupils that are unequal in size may indicate previous eye surgery or a serious neurologic problem, such as increased intracranial pressure. 4. The use of morphine and narcotic drugs may cause poor pupillary response to light. 5. One dilated and unresponsive pupil may indicate paralysis of the oculomotor nerve. Page Ref: 1679 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.2 Outline the components of the assessment of the eye and vision, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

33 ..

34) The nurse is preparing a teaching tool on eye health for a community fair. Which information should the nurse include about the frequency of eye examinations? Select all that apply. 1. Every year after the age of 60 2. Every 5 years until the age of 40 3. Every 3 years until the age of 50 4. Every 2 years until the age of 60 5. Every 6 months until the age of 10 Answer: 1, 4 Explanation: 1. An eye examination should be conducted yearly after the age of 60 by an optometrist or ophthalmologist. 2. An eye examination should be done every 2 years until the age of 60. 3. An eye examination should be done every 2 years until the age of 60. 4. An eye examination should be conducted at least every 2 years until the age of 60 by an optometrist or ophthalmologist. 5. An eye examination should be done every 2 years until the age of 60. Page Ref: 1689 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 45.6 Summarize topics that nurses teach to promote healthy vision and hearing across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the eye and ear collected during assessment and health promotion activities to support the health of this body system.

34 ..

35) After a routine physical examination, a patient is referred to a hearing specialist. Which assessment finding was used to support this referral? Select all that apply. 1. Reduced hearing 2. Ringing in the ears 3. Buildup of cerumen 4. Pink inner canal walls 5. Pearly gray tympanic membrane Answer: 1, 2 Explanation: 1. For any symptoms such as reduced hearing, a referral to an ear or hearing specialist should be made. 2. For any symptoms such as ringing in the ears, a referral to an ear or hearing specialist should be made. 3. Buildup of cerumen does not need a referral to a hearing specialist. 4. Pink inner canal walls are a normal finding. 5. Pearly gray tympanic membrane is a normal finding. Page Ref: 1689 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: VII.5. Use evidence-based practices to guide health teaching, health counseling, screening, outreach, disease and outbreak investigation, referral and follow-up throughout the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 45.6 Summarize topics that nurses teach to promote healthy vision and hearing across the lifespan. MNL Learning Outcome: 3. Interpret abnormal findings of the eye and ear collected during assessment.

35 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 46 Nursing Care of Patients with Eye and Ear Disorders 1) A patient who became blind in the left eye because of an industrial accident says, "I still have one good eye, and I can still do a lot." What should the nurse realize this patient is demonstrating? 1. Acceptance 2. Denial 3. Remorse 4. Anticipatory grieving Answer: 1 Explanation: 1. Acceptance of the change from sighted to blind is characterized by releasing the hope that vision will be regained. 2. Denial would be manifested by a refusal to believe that the condition is permanent. 3. Remorse involves feeling apologetic about the events. 4. Anticipatory grieving involves feeling sorrow for an upcoming event. Page Ref: 1693 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Grief and Loss Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

1 ..

2) The nurse is instructing a patient on the self-instillation of eye drops for acute conjunctivitis. What is the most important step for the nurse to teach this patient? 1. Ensure proper hand hygiene before instilling the drops. 2. Rub the eyes only when necessary. 3. Reuse cotton swabs as needed. 4. Insert contact lenses after the eye drops have been instilled. Answer: 1 Explanation: 1. Hand hygiene is the single most important measure to prevent transmission of infection to the eye. 2. Rubbing the eyes should be avoided as it can contribute to infection. 3. Reuse of cotton swabs should be avoided as it can contribute to infection. 4. Contact lenses should be avoided until the infection has resolved. Page Ref: 1695 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

2 ..

3) A patient is learning how to apply and care for a new set of contact lenses. What should the nurse include when teaching the patient about the use of these lenses? Select all that apply. 1. Wash hands before and after applying the lenses. 2. Eye pain is a common complaint and should not be a concern. 3. Distilled water is the best solution for the lenses. 4. Once applied, only remove when cloudy. 5. Contact eye physician if eyes become red or tear. Answer: 1, 5 Explanation: 1. Contact lens care includes hand hygiene. 2. Contact eye care professional if pain occurs. 3. Use appropriate wetting solution for the lenses; do not use homemade or solutions or water for the lenses. 4. Remove the lenses before sleep. 5. Contact eye care professional if eyes become red or tear. Page Ref: 1697 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

3 ..

4) A patient comes into the clinic complaining of "black spots and a curtain dropping" in the right eye. Which health problem should the nurse suspect is occurring with this patient? 1. Detached retina 2. Conjunctivitis 3. Sty 4. Cataract Answer: 1 Explanation: 1. Flashes of light, floaters, or the sensation of a curtain being drawn over the eye are indicators of retinal detachment. 2. Conjunctivitis presents with pain, redness, and possible discharge. 3. A sty would demonstrate swelling and tenderness. 4. Cataracts manifest with opacity of the eye. Page Ref: 1718 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

4 ..

5) A patient is diagnosed with a corneal abrasion. What should the nurse instruct this patient? 1. Do not share or use another person's eye makeup. 2. Only share a towel with family members. 3. Gently rub the eyes when itchy. 4. Use the prescribed eye drops until the symptoms disappear. Answer: 1 Explanation: 1. Teach all patients about proper eye care, including the importance of not sharing makeup. 2. Teach all patients about proper eye care, including the importance of not sharing towels. 3. Rubbing the eyes may further cause trauma or injury. 4. Prescribed medications must be taken as long as ordered. Page Ref: 1701 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

5 ..

6) A patient with an ectropion continues to experience eye dryness and corneal abrasions. What intervention might be indicated for this patient? 1. Corrective surgery 2. Corrective lenses 3. UV protective sunglasses 4. Contact lenses Answer: 1 Explanation: 1. In ectropion, surgery may be performed to correct the defect, reduce the risk of damage to the eye, and improve cosmetic appearance. 2. Corrective lenses would not be beneficial in correcting the eversion of the lid margin. 3. UV protective sunglasses would not be beneficial in correcting the eversion of the lid margin. 4. Contact lenses would not be beneficial in correcting the eversion of the lid margin. Page Ref: 1702 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

6 ..

7) A patient is hospitalized with blunt trauma to the left eye. To best minimize eye movement, what should the nurse do? 1. Patch or provide an eye shield for both eyes. 2. Place the patient in a side-lying position, with the eye up. 3. Keep the bed position flat. 4. Patch the unaffected eye. Answer: 1 Explanation: 1. Interventions for the patient with blunt trauma to the eye include protecting the eye from further injury with an eye shield. The unaffected eye should also be patched to minimize eye movement. 2. Interventions for the patient with blunt trauma to the eye include placing the patient on bed rest in semi-Fowler's position. 3. Interventions for the patient with blunt trauma to the eye include placing the patient on bed rest in semi-Fowler's position. 4. Interventions for the patient with blunt trauma to the eye include protecting the eye from further injury with an eye shield. The unaffected eye should also be patched to minimize eye movement. Page Ref: 1704 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

7 ..

8) An older patient with a mobility disorder is being discharged after having a cataract removed as an outpatient. For what should the nurse assess this patient? 1. Ability to administer eye drops post-procedure 2. Ability to read discharge instructions 3. Ability to drive 4. Ability to ambulate Answer: 1 Explanation: 1. Assess for factors that may interfere with the patient's ability to provide selfcare postoperatively. A chronic condition such as arthritis that may affect the ability to administer eye drops may indicate the need to include a family member in teaching. 2. A mobility disorder would not affect the patient's ability to read discharge instructions. 3. Driving is not related to the postoperative care required for this patient. 4. Ambulation is not related to the postoperative care required for this patient. Page Ref: 1707 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

8 ..

9) The nurse assesses a reduction in a patient's peripheral vision. Which additional measure would be a priority during the assessment of this patient? 1. Intraocular pressure assessment 2. Cranial nerve assessment 3. Neck range of motion assessment 4. Retinal assessment Answer: 1 Explanation: 1. Glaucoma is a condition characterized by optic neuropathy with gradual loss of peripheral vision and, usually, increased intraocular pressure of the eye. Measuring intraocular pressure is the priority, so that glaucoma can be diagnosed and appropriately treated. 2. Cranial nerve assessment may be performed as part of patient assessment; however, measuring intraocular pressure is the priority, so that glaucoma can be diagnosed and appropriately treated. 3. Neck range of motion may be performed as part of patient assessment; however, measuring intraocular pressure is the priority, so that glaucoma can be diagnosed and appropriately treated. 4. Retinal assessment may be performed as part of patient assessment; however, measuring intraocular pressure is the priority so that glaucoma can be diagnosed and appropriately treated. Page Ref: 1707 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

9 ..

10) A patient with COPD is being treated for glaucoma. Which medication should the nurse expect to be prescribed for this patient? 1. Adrenergic agonist 2. Beta-blocker 3. Calcium channel blocker 4. Antibiotic Answer: 1 Explanation: 1. An adrenergic agonist may be prescribed for patients with COPD. 2. Beta-blockers alone would be contraindicated in the treatment of glaucoma in patients with COPD. 3. Calcium channel blockers would not be useful in treating glaucoma. 4. Glaucoma is not caused by infection, so antibiotics are not useful. Page Ref: 1710 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

10 ..

11) A patient diagnosed with exudative macular degeneration reads as primary recreation. What should the nurse suggest to this patient? 1. Obtain books on tape or CD. 2. Find another activity that does not require reading. 3. Spend more time with friends and family. 4. Listen to music instead of watching so much television. Answer: 1 Explanation: 1. The nurse should provide other tools or items that can help compensate for diminished vision, such as books on tape. 2. This suggestion does not support the patient's interests. 3. This suggestion does not support the patient's interests. 4. This suggestion does not support the patient's interests. Page Ref: 1712 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

11 ..

12) A school-age child is having difficulty walking and seeing during the night. Which health problem should the nurse suspect is occurring with this patient? 1. Retinitis pigmentosa 2. Early macular degeneration 3. Detached retina 4. Glaucoma Answer: 1 Explanation: 1. The initial manifestation of retinitis pigmentosa, which is difficulty with night vision, is often noted during childhood. 2. The clinical manifestations that are described do not indicate early macular degeneration. 3. The clinical manifestations that are described do not indicate detached retina. 4. The clinical manifestations that are described do not indicate glaucoma. Page Ref: 1719 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

12 ..

13) A patient experiences an increase in ear pain when the auricle is pulled up and back. Which health problem should the nurse suspect is occurring with this patient? 1. Otitis externa 2. Otitis media 3. Otitis interna 4. Mastoiditis Answer: 1 Explanation: 1. The pain of otitis externa can be differentiated from that associated with otitis media by manipulating the auricle. 2. In external otitis, this maneuver increases the pain, whereas the patient with otitis media experiences no change in pain perception. 3. Otitis interna would not be manifested by pain on external manipulation. 4. Mastoiditis is a complication of otitis media and is manifested by recurrent earache and hearing loss of the affected side. Page Ref: 1720 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

13 ..

14) A patient is seen for hearing loss and odd popping noises in the left ear after "having a cold." Which potential problem should be considered for this patient? 1. Serous otitis media 2. Otitis externa 3. Acute otitis media 4. Otitis interna Answer: 1 Explanation: 1. Typical manifestations of serous otitis media include decreased hearing in the affected ear and complaints of "snapping" or "popping" in the ear. 2. Otitis externa is manifested by pain on manipulation of the external ear. 3. Acute otitis media is manifested by pain and hearing loss, but without complaints of "snapping" or "popping." 4. Otitis interna would be manifested by impairment of balance. Page Ref: 1723 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

14 ..

15) A patient with chronic acute otitis media infections is having tympanostomy tubes placed. What should post-tube placement instructions for this patient include? 1. Avoid getting any water into the ears. 2. Wash hair only with warm water. 3. Make sure showers are completed within 10 minutes. 4. Avoid gum chewing. Answer: 1 Explanation: 1. While the tube is in place, it is important to avoid getting any water in the ear canal because it may then enter the middle ear space. 2. Avoiding the introduction of water into the ear rather than the temperature of the water is the concern. 3. Avoiding the introduction of water into the ear rather than the length of showers is the concern. 4. Gum chewing may produce discomfort, but it is not as crucial as avoiding the introduction of water into the ear canal. Page Ref: 1724 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

15 ..

16) A patient with chronic otitis media is diagnosed with a cholesteatoma. What would be the treatment of choice for this patient? 1. Surgery 2. Nothing; it will resolve on its own 3. Antibiotics 4. Tympanostomy tubes Answer: 1 Explanation: 1. A cholesteatoma may require delicate surgery for its removal. If at all possible, radical mastoidectomy with removal of the tympanic membrane, ossicles, and tumor is avoided. 2. Untreated, the cholesteatoma can progressively destroy the ossicles and erode into the inner ear and cause profound hearing loss. 3. Antibiotics are not appropriate treatment. 4. Tympanostomy tubes are not used to treat a cholesteatoma. Page Ref: 1726 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

16 ..

17) A patient is experiencing a severe episode of Ménière disease. Which medication should the nurse expect to be prescribed to help reduce the sensation of spinning and nausea occurring in this patient? 1. Meclizine hydrochloride (Antivert) 2. Morphine sulfate 3. Digoxin (Lanoxin) 4. Droperidol (Inapsine) Answer: 1 Explanation: 1. Antivertigo/antiemetic medication such as meclizine hydrochloride (Antivert) is prescribed to reduce the whirling sensation and nausea. 2. Morphine is an opioid analgesic and would not be used to treat Ménière disease. 3. Digoxin (Lanoxin) is a cardiac glycoside and would not be used to treat Ménière disease. 4. Inapsine provides both a sedative and antiemetic effect. Page Ref: 1728 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

17 ..

18) The nurse is instructing a patient who has a hearing and balance disorder. What should be included in these instructions? Select all that apply. 1. Change positions slowly. 2. Turn the whole body, rather than just the head. 3. Stand very still with the onset of vertigo. 4. Increase pace of ambulation. 5. Avoid reclining while taking antivertigo medication. Answer: 1, 2 Explanation: 1. The patient should be instructed to change positions slowly. 2. The patient should be instructed to turn the whole body rather than just the head. 3. The patient should be instructed to sit down immediately with the onset of vertigo. 4. The patient should be instructed to lie down if possible. 5. It is not necessary to avoid reclining while taking antivertigo medication. Page Ref: 1729 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

18 ..

19) An older patient often responds incorrectly to questions or during general conversation. For which health problem should this patient be assessed? 1. Hearing disorder 2. History of strokes 3. Level of education 4. Cognitive impairment Answer: 1 Explanation: 1. Inappropriate responses due to a hearing deficit can cause others to perceive the patient as "stupid" or demented. 2. Inappropriate responses due to a hearing deficit can cause others to perceive the patient as "stupid" or demented. 3. Level of education is unrelated to the issue of inappropriate responses. 4. Cognitive impairment is unrelated to the issue of inappropriate responses. Page Ref: 1735 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

19 ..

20) A patient who is a single parent of two young children has recently lost vision in one eye following a car accident. Which problem should the nurse address as being high priority with this patient? 1. Grieving 2. Change in family functioning 3. Possible change in self-esteem 4. Potential for injury 5. Fear of future trauma Answer: 1, 2, 3 Explanation: 1. Although adaptation may be easier for the patient who experiences a gradual loss of vision than for someone with an abrupt loss, both must grieve the lost sense. The patient who becomes blind needs to grieve the lost body function as well as the loss of mobility, self-sufficiency, perhaps economic security, and, to a certain extent, contact with reality as it has been perceived. 2. Interpersonal relationships and roles are affected. Communication patterns change with the loss of the ability to perceive many nonverbal cues. 3. The patient's self-concept and self-esteem are threatened. Anger, denial, remorse, and selfpity are not uncommon in the initial period following loss of sight. 4. The patient still has some sight. The potential for injury is not of a high priority at this time. 5. There is no evidence that the patient will have a fear of future traumatic events. Page Ref: 1693-1694 Cognitive Level: Analyzing Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

20 ..

21) A patient who has been blind since birth is admitted to the hospital. Which action should the nurse take when caring for this patient? Select all that apply. 1. Orient the patient verbally and physically to the layout of the room. 2. Leave the room door partially open. 3. Place signs to remind staff not to move equipment. 4. Ensure the television is on at all times. 5. Tell the patient you will leave the light on 24 hours a day. Answer: 1, 3 Explanation: 1. Orienting the patient verbally and physically allows the patient to understand the location of items and what is present in the room. 2. Leave doors either fully open or closed as the patient wishes, but, to preserve safety, do not leave doors partially open. 3. Posting a sign as a reminder to leave equipment (chairs, tables, etc.) in the same location will minimize the risk of injury when the patient is ambulating in the room. Staff from other departments might not be familiar with the patient's special needs, and a reminder will contribute to the patient's well-being. 4. Sensory stimuli such as a television should be used as desired by the patient. 5. Telling the patient that a light will be on does not increase safety for a patient that has no vision. In some cases, even though the patient is blind, this action can alter the sleeping pattern of the patient. Page Ref: 1693-1694 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

21 ..

22) A patient is recovering from a myringotomy for acute otitis media. What should the nurse emphasize with this patient? 1. Avoid sudden changes in barometric pressure. 2. Ear irrigations should be placed on the wall of the external canal. 3. Sterile, cotton-tipped swabs can be used to clean the ear drainage. 4. Swimming is restricted for approximately two weeks. Answer: 1 Explanation: 1. The patient should be instructed to avoid sudden changes in air pressure. 2. No ear irrigations should be done during the postoperative as solution could enter through the tubes and contaminate the middle ear. 3. Sterile swabs are not to be placed in the external canal because of the potential of dislodging the tubes, as well as the potential for middle ear contamination. Therefore, nothing should be inserted into the ear following surgery. A sterile cotton ball can be placed loosely at the external opening of the ear, not in the canal or near the tympanic membrane, to collect any drainage, but it should not be packed deeply into the ear canal. 4. Swimming, submerging in water, and getting water in the ear are contraindicated for several months (not weeks) due to the risk of water contamination in the middle ear. Page Ref: 1725 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

22 ..

23) A patient is recovering from keratoplasty. What information should be included in the nursing plan of care? Select all that apply. 1. Wear an eye shield the first 24 hours and then at night until several weeks postoperatively as directed by healthcare provider. 2. Avoid lifting, sneezing, coughing, or bending over at the waist. 3. Report any change noted, such as increased pain, drainage, bleeding, floaters, and cloudiness. 4. Administer all eyedrops and ointments in a sterile manner. 5. Administer mydriatics during the postoperative period. Answer: 1, 2, 3, 4 Explanation: 1. An eye shield is needed to remind the patient not to touch or bump the eye until complete healing of the corneal transplant has occurred. At night, the eye is protected to avoid possible scratching or trauma while asleep. 2. Lifting, sneezing, coughing, or bending will increase intraocular pressure and should be avoided while the corneal transplant is healing. 3. Any change (pain, drainage, bleeding, floaters, or cloudiness) should be reported immediately, since a complication might have developed (e.g., rupture of suture, infection, internal tears). 4. The use of sterile technique is needed for eye medication after surgery to prevent introduction of bacteria or trauma from touching the eye. 5. Mydriatics will dilate the pupil of the eye and increase intraocular pressures. Therefore, they are not given postoperatively because they will minimize blood flow and healing. Mydriatics are used in the preoperative phase to visualize the internal structures. Page Ref: 1699 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

23 ..

24) The nurse is planning care for a patient with severe symptoms of tinnitus, vertigo, sensorineural hearing deficit, nausea, and vomiting. What issue should the nurse identify as a priority for this patient? 1. Anticipating future attacks 2. Ensuring adequate nutritional intake 3. Problems with interpersonal relationships 4. Difficulty sleeping Answer: 1 Explanation: 1. The symptoms listed are for labyrinthitis and Ménière disease, a disorder of the inner ear that disturbs all balance and coordination of motor skills related to gravitational pulls. Because of the unpredictable nature of attacks, the patient with vertigo due to an inner ear disorder needs to learn strategies for dealing with an acute episode. 2. Although the patient is experiencing nausea and vomiting, there is no evidence that this will be prolonged. 3. There is no evidence that the patient will have problems with interpersonal relationships because of the health problem. 4. Some patients might have difficulty sleeping; however, this is not a priority since the patient is not experiencing a change in sleep at this time. Page Ref: 1729 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

24 ..

25) The nurse is identifying interventions for a patient with a hearing deficit. What should be included in this patient's plan of care? Select all that apply. 1. Speak face-to-face, but do not overarticulate your words. 2. Offer alternative methods of communication, such as paper and pencil. 3. Use facial and hand gestures while talking. 4. Speak loudly and in a higher pitch for easier understanding of words. 5. Restate in exactly the same words if not understood the first time. Answer: 1, 2, 3 Explanation: 1. Many patients with hearing deficits can read lips to some extent to assist in the communication process. Facing away from the patient does not alert the patient to the need to communicate. 2. Offering alternative methods of communication can allow for independence and clarity of communication if the patient chooses to use another method. The nurse allows the patient to maintain self-esteem and input to personal management. 3. Facial gestures and hand gestures (nonverbal cues) contribute to communication; therefore, they are not distracting but helpful. 4. Do not speak louder; use a deeper tone for better understanding, since higher pitch is lost first with most hearing problems. 5. Do not use the same words, since the consonants or vowels are not being understood. Try alternative words or methods of communication. Repeating the same words is frustrating for both persons. Page Ref: 1735 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

25 ..

26) The nurse is preparing to conduct a physical assessment on a patient with otosclerosis. Which finding should the nurse anticipate in this patient? 1. Rinne test results show that bone conduction is equal or greater than air conduction. 2. Severe vertigo is present when questioned. 3. Purulent drainage is observed or reported with cyanosis of the tympanic membrane. 4. Diminished hearing is noted in the lower tones, such as a man's speaking voice. Answer: 1 Explanation: 1. The Rinne test differentiates between bone and air conduction. In otosclerosis, there is greater bone conduction due to the calcification and fixation of the malleus, incus, and stapes (bony ossicles). Talking on the phone is retained longer than direct verbal communication, since it involves bone conduction rather than air conduction. 2. Severe vertigo is the hallmark symptom of inner ear disturbances, not the middle ear stapes fixation associated with otosclerosis. 3. Purulent drainage with cyanosis of the tympanic membrane represents an acute or chronic middle ear infection that has caused a rupture of the tympanic membrane. Infection is not related to otosclerosis. 4. Diminished hearing begins in the upper tones or higher pitches that are lost first. Lower tones, such as the deeper pitch of men's voices, are more easily heard by a patient with otosclerosis. Page Ref: 1726 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

26 ..

27) A patient is being treated for an eye infection. Which instruction should the nurse provide the patient about self-care? Select all that apply. 1. "You should wash your hands before cleansing your eye and putting in eyedrops." 2. "You can soak your lids with warm saline to soften crusts and exudates." 3. "You should not share towels, makeup, or contact lenses with anyone else." 4. "You can apply warm compresses to ease inflammation." 5. "You can rub your eyes with a clean, soft cloth for itching." Answer: 1, 2, 3, 4 Explanation: 1. Hand hygiene will minimize cross-contamination and the risk of bringing other organisms to an already infected eye. Hand hygiene should be encouraged at all times, but especially when infection is present. 2. Soaking the lids with warm saline softens the crusts from exudates that accompany Staphylococcus infection. 3. Sharing supplies, such as towels, makeup, or contacts, is inappropriate due to potential for cross-contamination from person to person. But during an actual infection, instructions should include not using the same equipment after the infection is cleared. Towels should be washed in hot water. Makeup and contacts should be discarded and not reused. 4. Teach to apply warm compresses to reduce inflammation and discomfort. 5. Rubbing the eyes can traumatize them further and risks cross-contamination if only one eye is infected, and should not be encouraged. Page Ref: 1695, 1696 Cognitive Level: Applying Client Need & Sub: Safe and Effective Care Environment: Safety and Infection Control Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

27 ..

28) The nurse is reviewing medications prescribed for patients with open-angle glaucoma. Which medication should the nurse question? 1. Timolol (Timoptic), beta-adrenergic blocker, for a 60-year-old with congestive heart failure (CHF) 2. Dorzolamide (Trusopt), a carbonic anhydrase inhibitor, for a patient with asthma and chronic obstructive pulmonary disease (COPD) 3. Acetazolamide (Diamox) for a 20-year-old male 4. Brimonidine (Alphagan), an adrenergic agonist, for a healthy 40-year-old Answer: 1 Explanation: 1. Timolol (Timoptic) is a selected beta-adrenergic blocker that will reduce the intraocular pressure by decreasing production of aqueous humor. Its systemic effects might limit its use for patients with congestive heart failure (CHF). The nurse should question the use of this medication with a patient with CHF. 2. Dorzolamide (Trusopt) lowers intraocular pressure, and is often an adjunctive therapy that removes fluids through kidney filtration. It is a carbonic anhydrase inhibitor that is contraindicated in closed-angle glaucoma, renal disease, and allergy to sulfa, but is indicated for open-angle glaucoma. This order is appropriate for this patient. 3. Acetazolamide (Diamox) is a carbonic anhydrase inhibitor used as an adjunctive therapy to remove fluids through kidney filtration. A healthy 20-year-old would not have contraindications unless allergic to sulfa drugs. This would not be questioned by the nurse. 4. Brimonidine (Alphagan) is based on an epinephrine, sympathomimetic drug action to dilate the pupil and reduce the production of aqueous humor in patients with open-angle glaucoma. This drug is appropriate if no hypertension or cardiac disease is present, such as in a healthy 40year-old. Page Ref: 1711 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

28 ..

29) A patient with keratitis is to have diagnostic testing. What should the nurse anticipate being prescribed for this patient? 1. Fluorescein staining with slit-lamp examination 2. Photoreactive keratectomy 3. Computed tomography (CT) scan 4. Glycerol test Answer: 1 Explanation: 1. Keratitis is an inflammation of the cornea that results in scarring. Fluorescein stain with a slit-lamp examination allows visualization of corneal ulcerations that is a manifestation of keratitis. 2. Photoreactive keratectomy is a procedure using a laser to reshape the cornea and correct refractive errors. 3. A CT scan would be indicated if a foreign body is suspected. 4. A glycerol test is conducted to diagnose Ménière disease. Page Ref: 1694 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

29 ..

30) A young child is being seen with an impaction of the ear canal by a large plastic bead. Which procedure should the nurse expect to be used to remove this object? 1. Suction using a soft piece of tubing 2. Instillation of lidocaine drops 3. Instillation of mineral oil 4. Forceps Answer: 1 Explanation: 1. Smooth, round objects present a challenge to remove from the ear. Suction applied using a piece of soft tubing may be effective. 2. The instillation of lidocaine drops would not penetrate the ear canal. 3. The instillation of mineral oil would not penetrate the ear canal. 4. Forceps would not grasp the object and could damage the ear canal if force is applied. Page Ref: 1722 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

30 ..

31) A young soldier recovering from enucleation due to traumatic injury is concerned that his significant other will not want to continue the relationship. What is an appropriate response by the nurse? 1. "You'll probably get your temporary prosthesis in a week and your permanent one in 1 or 2 months. Most people won't know which eye is which." 2. "I wouldn't worry; your girlfriend is not going to give up on you." 3. "Your hearing aid will be nearly invisible; no one will know you have one." 4. "Why don't you tell a couple of your friends to bring you a pizza? That will cheer you up." Answer: 1 Explanation: 1. Approximately 1 week after an enucleation, a temporary eye prosthesis will be put in place; a permanent prosthesis is fitted 1 to 2 months following surgery. Often it is difficult to discern which eye is functional and which is the prosthesis. This patient is concerned about his appearance and addressing this issue while offering information and encouragement is appropriate. 2. The nurse does not know the feelings of the girlfriend. 3. An enucleation involves the eye, not the ear. 4. Telling the patient that his friends will cheer him up is avoiding his concern about the possible change to his appearance. Page Ref: 1719-1720 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Caring Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

31 ..

32) The nurse is talking with a member of the family of a patient who had surgery for a cochlear implant. Which statement by the family member is correct? 1. "A cochlear implant won't replace normal hearing; it will improve sound perception." 2. "It will be much nicer than a hearing aid, as nothing needs to be worn or will be visible." 3. "The speaking voice will improve, too." 4. "It will be less expensive than a hearing aid since you don't have much equipment." Answer: 1 Explanation: 1. A cochlear implant assists in restoring sound perception and does not replace normal hearing. 2. A cochlear implant consists of a microphone, speech processor, transmitter and receiver/stimulator, and electrodes. The transmitter is placed on the scalp over the receiver/stimulator, which is connected to the microphone and speech processor worn on the body. 3. A cochlear implant will not improve voice quality, but it allows the patient to focus on the person speaking, which improves communication. 4. A cochlear implant consists of a microphone, battery-powered speech processor, transmitter and receiver/stimulator, and electrodes. Hearing aids involve less equipment. Page Ref: 1734 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Communication and Documentation Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

32 ..

33) The nurse is completing a health history interview of a patient with a suspected diagnosis of retinitis pigmentosa. What question should the nurse ask this patient during the interview? Select all that apply. 1. Do you have any health problems that have a genetic basis? 2. Do you know if your parents have had or your children are experiencing any symptoms similar to what you are experiencing? 3. What is your current occupation? 4. Have you ever suffered blunt trauma to the head? 5. Have you ever been told you were HIV positive? Answer: 1, 2, 3 Explanation: 1. Retinitis pigmentosa may be associated with other genetic defects. 2. Retinitis pigmentosa is a hereditary degenerative disease. It is an autosomal dominant, autosomal recessive, or X-linked trait. 3. Initial manifestations are noted in childhood, and the patient may be totally blind by age 40. Therefore, consideration of occupation is important, as the patient may be referred to vocational rehabilitation services. 4. This disease is not associated with blunt trauma to the head, although this question would be relevant to any patient with a suspected eye disorder. 5. This disease is not associated with HIV infection, although this question would be relevant to any patient with a suspected eye disorder. Page Ref: 1719 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

33 ..

34) The nurse is teaching a community education class on prevention of eye injuries and care of someone with an eye injury. What should be included in this presentation? Select all that apply. 1. Eye protection devices should be worn when participating in high-risk sports or occupations. 2. Use of seat belts and air bags prevents eye injuries in automobile crashes. 3. In case of injury, immediately flush the eye with copious amounts of water if a chemical splash occurs. 4. Loose, visible objects can be removed using a clean, moistened cotton-tipped swab. 5. If an object appears to penetrate the eye, gently remove it using sterile gauze and seek medical attention. Answer: 1, 2, 3, 4 Explanation: 1. Teaching related to eye injuries focuses on prevention and first-aid measures. Eye protection devices should be worn when participating in high-risk sports or occupations. 2. Use of seat belts and air bags prevents eye injuries in automobile crashes. 3. In case of injury, immediately flush the eye with copious amounts of water if a chemical splash occurs. 4. Loose, visible objects can be removed using a clean, moistened cotton-tipped swab. 5. If an abrasion, penetrating injury, or blunt injury is suspected, the eye should be covered loosely with sterile gauze and medical attention sought immediately. Instruct patients not to remove objects that penetrate the eye. Page Ref: 1705 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

34 ..

35) A patient with a hordeolum (sty) asks what caused the disorder. What is the nurse's best response? 1. "This may be due to the dandruff on your scalp and eyebrows." 2. "This is possibly a side-effect of a medication you are taking." 3. "It is a result of eversion of the eyelid and associated with the aging process." 4. "It may be due to squinting when you are in the sun and not wearing sunglasses." Answer: 1 Explanation: 1. A hordeolum (sty) is an infection of one or more of the sebaceous glands of the eye. It can be caused by a staphylococcal infection or it may be due to dandruff of the scalp and eyebrows, which would be seborrheic in origin. 2. There is not enough information to determine whether medication the patient is taking could be a possible cause. 3. Eversion of the eyelid is an ectropion and can result from an infectious process, but it is typically age-related. 4. Squinting is not the cause of a sty. Page Ref: 1701 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

35 ..

36) The nurse is asked by a patient with diabetes actions to take to preserve vision. What is the best response by the nurse? 1. "The risk of developing blindness is related to how long you've had diabetes, and how well your blood sugar and hypertension are controlled." 2. "Blindness from diabetes is due to the small blood vessels in the eye becoming hardened and clogged and not being able to transport oxygen and nutrients to the retina." 3. "This is only a problem with type 2 diabetes, so you won't have this problem." 4. "Laser photocoagulation surgery will treat any problems that develop and stop the progression of diabetic retinopathy." Answer: 1 Explanation: 1. The risk of developing diabetic retinopathy is related to the duration of the diabetes and the degree of glycemic control. Hypertension is also a risk factor. 2. Although the retinal capillaries become sclerotic and lose their ability to transport sufficient oxygen and nutrients to the retina, this statement does not answer the patient's question. 3. Diabetic retinopathy is seen in both type 1 and type 2 diabetes. 4. Laser photocoagulation is used to treat both forms of diabetic retinopathy; however, it does not cure the disease. Page Ref: 1717 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

36 ..

37) The nurse is preparing to provide eardrops for a patient. Place the following steps in the correct order when administering this medication. Choice 1. Warm the medication by placing it in the hand or pocket for a few minutes. Choice 2. Tilt the patient's head toward the unaffected side. Choice 3. Straighten the ear canal by pulling the pinna up and back, using the nondominant hand. Choice 4. Insert the prescribed number of drops into the ear canal. Choice 5. Have the patient remain in position for approximately 5 minutes. Choice 6. Loosely place a cotton ball at the auditory meatus for 15 to 20 minutes. Answer: 1, 2, 3, 4, 5, 6 Explanation: Choice 1. The correct procedure for instilling eardrops begins with hand hygiene and warming the medication. Hold the container or place it in the pocket for a few minutes. Choice 2. Have the patient tilt the head toward the unaffected side. Choice 3. Using the nondominant hand, straighten the ear canal by pulling the pinna up and back. Choice 4. Instill the correct number of drops into the ear canal. Choice 5. Have the patient remain in position for approximately 5 minutes. Choice 6. Place a cotton ball loosely in the auditory meatus for 15 to 20 minutes. Page Ref: 1721 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

37 ..

38) The nurse knows that a patient may develop sensorineural hearing loss as a result of ototoxic drugs. Which patient would be at the highest risk for this type of hearing deficit? 1. Patient with methicillin-resistant Staphylococcus aureus (MRSA) on high doses of vancomycin (Vancocin) 2. Patient on low-dose aspirin to prevent stroke 3. Patient on steroids (Prednisone) for chronic spondylolisthesis 4. Patient using atorvastatin (Lipitor) to prevent heart disease and stroke Answer: 1 Explanation: 1. Ototoxic drugs damage the hair cells of the organ of Corti resulting in sensorineural hearing loss. Ototoxic drugs include vancomycin (Vancocin). 2. A patient taking low-dose aspirin is at a lesser risk than a patient taking high doses of vancomycin. 3. Steroids are not ototoxic. 4. Atorvastatin is not ototoxic. Page Ref: 1731 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for patients with eye and ear disorders.

38 ..

39) During an assessment, the nurse notes that a patient has conjunctival erythema around the cornea. On which health problem should the nurse focus when continuing with the assessment of this patient? Select all that apply. 1. Acute uveitis 2. Corneal trauma 3. Corneal infection 4. Acute conjunctivitis 5. Acute angle-closure glaucoma Answer: 1, 2, 3, 5 Explanation: 1. Conjunctival erythema is around the cornea in acute uveitis. 2. Conjunctival erythema is around the cornea in corneal trauma. 3. Conjunctival erythema is around the cornea in corneal infection. 4. In acute conjunctivitis, erythema is diffuse. 5. Conjunctival erythema is around the cornea in acute angle-closure glaucoma. Page Ref: 1695 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for patients with eye and ear disorders.

39 ..

40) A patient with acute angle-closure glaucoma is prescribed the prostaglandin analog bimatoprost (Lumigan). What should the nurse include when instructing the patient about this medication? Select all that apply. 1. This drug causes the iris to darken. 2. This drug causes eyelashes to grow. 3. Use once daily at bedtime as directed. 4. Remove contact lenses before using this drug. 5. Skin discoloration around eyebrows will reverse. Answer: 1, 2, 3, 4 Explanation: 1. The nurse should instruct the patient that this drug may cause darkening of the iris. 2. The nurse should instruct the patient that this drug may cause increased growth of the eyelashes. 3. The nurse should instruct the patient to use the medication once daily at bedtime as directed. Because this drug may blur vision, using it at bedtime minimizes associated safety risks. 4. The nurse should instruct the patient to remove contact lenses before administering the drug. 5. The nurse should instruct the patient that this drug may cause darkening of the skin around the eyes. This color change is permanent but will not progress if the drug is discontinued. Page Ref: 1711 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.1 Describe the pathophysiology and manifestations of eye disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for patients with eye and ear disorders.

40 ..

41) The nurse provides a training session to a group of lifeguards at a community pool on actions to prevent the development of otitis externa. Which participant statements indicate that no additional teaching is required? Select all that apply. 1. "I should use a tight-fitting swim cap." 2. "I should use silicone earplugs when in the water." 3. "I can use a cotton swab to absorb water in the ear." 4. "I can use a hair dryer on the low setting to dry the ear canal." 5. "I should make sure the pool water has been disinfected before entering." Answer: 1, 2, 4, 5 Explanation: 1. The nurse should instruct the lifeguards to wear a tight-fitting swim cap to keep water out of the ears. 2. The nurse should instruct the lifeguards to use silicone earplugs, which can keep water out of the ear without reducing hearing significantly. 3. The nurse should instruct the lifeguards to avoid inserting cotton swabs into the ear canal. 4. The nurse should instruct the lifeguards to dry the ear canal with a hair dryer on the lowest setting. 5. The nurse should instruct the lifeguards to make sure the pool has been disinfected before entering. Page Ref: 1721 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

41 ..

42) A patient with conductive hearing loss has selected a behind-the-ear hearing aid with earmold. What should the nurse reinforce with the patient as advantages of this device? Select all that apply. 1. Easy to manipulate 2. Most versatile and reliable 3. Comfortable and least visible 4. Allows fine amplification level adjustments 5. Can be incorporated into the temple of eyeglasses Answer: 1, 2, 4, 5 Explanation: 1. The behind-the-ear hearing aid with earmold is easier to manipulate. 2. The behind-the-ear hearing aid with earmold is most versatile and reliable. 3. The behind-the-ear hearing aid with earmold is the most visible device. 4. The behind-the-ear hearing aid with earmold allows for finer amplification adjustments. 5. The behind-the-ear hearing aid with earmold can be incorporated into the temple of eyeglasses. Page Ref: 1733 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 46.2 Describe the pathophysiology and manifestations of ear disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for patients with eye and ear disorders.

42 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 47 Assessing the Male and Female Reproductive Systems 1) A 40-year-old male seeks medical attention for impotence. Which patient statement should the nurse further investigate? Select all that apply. 1. "I take medications to help me sleep several times per week." 2. "I had the mumps when I was a boy." 3. "I had a vasectomy 4 years ago." 4. "I have had diabetes for several years." 5. "My wife has a history of cervical cancer." Answer: 1, 4 Explanation: 1. The causes of impotence may be related to medication use, performance anxiety, or chronic disease processes. The patient who takes tranquilizers or medications for sleep may experience impotence. 2. Having the mumps may result in male infertility, not impotence. 3. Having a vasectomy results in sterility, not impotence. 4. Diabetes mellitus over time may cause vascular damage, resulting in impotence. 5. The presence of cervical cancer in a partner is not linked to impotence. Page Ref: 1742 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

1 ..

2) While collecting data from a couple experiencing infertility, the male partner, age 52, asks why information about his mother's pregnancy is important. How should the nurse respond? 1. "Collecting information about a patient's immediate family is required." 2. "Medication exposure during pregnancy may impact the long-range fertility of the woman's male children." 3. "If your mother experienced infertility, you are at a higher risk for infertility." 4. "Although the greater concerns relate to the female's mother, we collect information on both of you to create a more balanced picture." Answer: 2 Explanation: 1. Data is collected to ensure a complete picture of the patient's past and current history and is incorporated into the assessment and subsequent treatment plans. This response, however, does not meet the patient's need for clarification. 2. Men born to women treated during pregnancy with diethylstilbestrol (DES), a drug used in the 1940s and 1950s to prevent miscarriage, may have congenital deformities of the urinary tract as well as reduced semen levels. 3. The possible infertility of the male partner's mother would not impact his current ability to father children. 4. Both the male and female will need to provide a comprehensive history in the assessment period. Neither partner's history is of greater importance at this point. Page Ref: 1742 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 47.1 Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the male and female reproductive systems.

2 ..

3) The nurse is performing an assessment of a female patient's breasts. Which finding indicates the need for further assessment? Select all that apply. 1. The breasts are not the same size. 2. The breasts do not display prominent veins. 3. The nipples are flat. 4. The breasts are reddened. 5. There is an area of dimpled skin. Answer: 4, 5 Explanation: 1. It is normal for the breasts to differ in size. 2. The absence of prominent veining is normal. 3. The nipples are usually everted but may normally be inverted or flat. 4. Reddened skin of the breast indicates the possible presence of a malignancy. 5. Dimpling and abnormal contours should be further evaluated. Page Ref: 1749 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

3 ..

4) A patient is scheduled to have a vaginal examination and a Pap smear. Which patient statement indicates understanding of the nurse's instruction concerning the test and preparation? 1. "I cannot bathe for 36 hours prior to the examination." 2. "I should not douche the day before my examination." 3. "My period will not be a reason to defer my vaginal examination." 4. "My physician will use Vaseline to lubricate the speculum and prevent discomfort." Answer: 2 Explanation: 1. Tub baths should be avoided for 24 hours prior to the test. 2. The patient should be advised not to douche for 24 hours prior to the test. 3. Menstruation and vaginal infections may warrant postponement of the testing. 4. Vaseline is not water soluble and should not be used on the speculum if cells are going to be obtained for testing. Page Ref: 1751 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the male and female reproductive systems.

4 ..

5) An adolescent patient is having a first vaginal examination. Which speculum should the nurse prepare for this examination? 1. Graves speculum 2. Pederson speculum 3. Killian speculum 4. Vienna speculum Answer: 2 Explanation: 1. The Graves speculum is used for the adult woman. 2. The Pederson speculum is narrower and is used for adolescents or adult women who are virgins, have never had a baby, or are postmenopausal with vaginal atrophy. 3. The Killian speculum is used to examine the nasal passages. 4. The Vienna speculum is used to examine the nasal passages. Page Ref: 1751 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the male and female reproductive systems.

5 ..

6) A pregnant patient overhears the examiner referring to a positive Hegar sign and asks what this means. Which response by the nurse best explains this sign? 1. Hegar sign refers to the softening of the lower uterine segment during pregnancy. 2. Hegar sign refers to the skin changes noted in early pregnancy. 3. Hegar sign refers to the softening of the cervix during the early stages of pregnancy. 4. Hegar sign refers to the changes in color of the vaginal mucosa during pregnancy. Answer: 1 Explanation: 1. During pregnancy, the lower uterine segment or isthmus softens in response to hormonal changes. This phenomenon is referred to as Hegar sign. 2. Skin changes during pregnancy include linea nigra and chloasma, not Hegar sign. 3. A softening of the cervix during pregnancy is known as Goodell sign. 4. The change in color of the vaginal mucosa during pregnancy is known as Chadwick sign. Page Ref: 1751 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

6 ..

7) During the bimanual examination of a patient's uterus, the nurse notes that the uterus is tilted toward the back. What should the nurse explain to the patient about this finding? 1. The uterus of a patient who has carried a child to term is frequently in a tilted-back position. 2. The uterus may be tilted backward (retroverted) or angled backward (retroflexed). 3. The uterus of a patient with fibroid tumors frequently tilts back under the weight of the tumors. 4. The backward tilt of the uterus is consistent with pregnancy in the second or third trimester. Answer: 2 Explanation: 1. This anatomical positioning of the uterus is not related to pregnancy. 2. The uterus may be tilted backward (retroverted) or angled backward (retroflexed). 3. This anatomical positioning of the uterus is not related to the presence of fibroid tumors. 4. This anatomical positioning of the uterus is not related to pregnancy. Page Ref: 1751 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

7 ..

8) The nurse is conducting a presentation to a group of women concerning menopause. Which statement by a participant indicates an understanding about the process? Select all that apply. 1. "Lubrication for intercourse will not be as necessary after menopause." 2. "My risk for vaginal infections declines as my estrogen levels decrease during menopause." 3. "My uterus will shrink in size after menopause." 4. "My skin will thicken after menopause." 5. "I should start practicing Kegel exercises." Answer: 3, 5 Explanation: 1. The loss of estrogen is responsible for the reduction of vaginal lubrication. Patients experiencing this loss may require lubricants to promote comfort during sexual intercourse. 2. The vaginal dryness associated with menopause raises the risk for vaginal infections. 3. The uterus shrinks in size during menopause. 4. The skin thins during menopause. 5. Weakening of the pelvic floor muscles may contribute to involuntary incontinence. Page Ref: 1756 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 47.5 Differentiate considerations for assessing the reproductive systems of older adults and of individuals in the LGBTQI population. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

8 ..

9) The nurse is scheduling a hysterosalpingogram test for a patient. When planning the test, which information from the patient's history will the nurse need? 1. Date of the patient's last menstrual period (LMP) 2. Number of past pregnancies the patient has had 3. Type of contraceptive being used by the patient and her partner 4. Patient's age at menarche Answer: 1 Explanation: 1. The hysterosalpingogram is performed to assess the uterus and fallopian tubes for abnormalities. The test is performed on days 7 to 9 after the menstrual period. Knowledge of the patient's LMP will be useful when planning the test. 2. The test is often used as a diagnostic test for patients experiencing infertility, but the number of past pregnancies is not relevant to scheduling the test. 3. The test is often used as a diagnostic test for patients experiencing infertility, but the type of contraceptive being used is not relevant to scheduling the test. 4. The test is often used as a diagnostic test for patients experiencing infertility, but the age at menarche is not relevant to scheduling the test. Page Ref: 1754 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

9 ..

10) A patient is scheduled to have an endometrial biopsy. After the nurse provides education concerning the test, which patient statement indicates an understanding of the procedure? 1. "I may need a strong pain medication for the first several days after the test." 2. "I may not have a regular menstrual cycle for 3 to 6 months after the test." 3. "If I have bleeding after the procedure, I can use junior-size tampons." 4. "I should avoid sexual intercourse in the days following the procedure." Answer: 4 Explanation: 1. The procedure may be uncomfortable, but the pain should not require the use of strong analgesics for several days afterward. 2. The menstrual cycle may be interrupted, but not for an extended period of time. 3. The patient will likely have vaginal bleeding in the days after the procedure. Pads are indicated for any vaginal bleeding. Tampons are contraindicated. 4. The endometrial biopsy is performed to identify endometrial hyperplasia or cancerous cells. The patient will likely have vaginal bleeding in the days after the procedure and is instructed to avoid intercourse while bleeding. Page Ref: 1754 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

10 ..

11) During the vaginal examination of a 33-year-old patient, a nontender mass at the posterolateral portion of the labia majora is noted. What should the nurse suspect is occurring with the patient? 1. Rectocele 2. Fistula 3. Bartholin cyst 4. Cyst of Skene's gland Answer: 3 Explanation: 1. A rectocele is a protrusion of the rectal wall into the vaginal canal. 2. A fistula results is an opening between two anatomically separate organs. 3. The Bartholin gland is located at the posterolateral labia majora. This gland provides lubrication to the female genitalia. A swelling in this area is consistent with the diagnosis of Bartholin's cyst. 4. Skene's glands are located on the anterior vaginal walls. Page Ref: 1750 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

11 ..

12) An 18-year-old female patient who reports feeling two nonpainful ulcerations on the labia asks if they might be herpes simplex. What response should the nurse make? 1. "Those spots do sound consistent with herpes simplex." 2. "Have you been having sex with new partners?" 3. "Herpes lesions are usually painful." 4. "The lesions you describe are most consistent with genital warts." Answer: 3 Explanation: 1. The patient's description is not consistent with herpes simplex. Herpes lesions are typically painful. 2. It will be important to assess the patient's sexual activity, but this line of questioning does not address the patient's most immediate questions and concerns. 3. The patient's description is not consistent with herpes simplex. Herpes lesions are typically painful. Nonpainful ulcerations are suggestive of syphilis. 4. Genital warts present as fleshy, nonpainful growths. Page Ref: 1750 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

12 ..

13) The nipples of a 22-year-old female patient's breasts are pointing in different directions. What action should the nurse take? 1. The findings should be documented as normal. 2. The nurse will need to question the patient to determine if she is breastfeeding. 3. The finding will need to be reported for follow-up hormone level assessments. 4. The finding will need to be reported for further testing to rule out a malignancy. Answer: 4 Explanation: 1. This finding is not normal. 2. Breastfeeding would not affect the direction in which the nipples point. 3. Hormone levels may be associated with nipple discharge but not with asymmetry in their direction. 4. The nipples should point in the same direction. Asymmetry in direction may indicate the presence of a malignancy. Page Ref: 1749 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

13 ..

14) A patient who had an exploratory laparoscopic surgical procedure 36 hours ago reports feeling shoulder pain. How should the nurse respond? 1. "The surgical table is famous for causing patients shoulder pain after procedures." 2. "You are likely not sleeping well, which can lead to shoulder discomfort." 3. "This pain is caused by the gases used during the surgical procedure." 4. "This pain should go away soon." Answer: 3 Explanation: 1. The surgical table is not the most likely source of the patient's discomfort. 2. The patient may not be sleeping well in the days after surgery, but this is not the most logical reason for the shoulder discomfort. 3. When performing laparoscopic surgery, the physician uses carbon dioxide to raise the organs and improve visualization. This often results in shoulder discomfort during the postoperative period. 4. The pain will subside, but this response does not address the educational needs of the patient. Page Ref: 1755 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

14 ..

15) A patient who had a laparoscopic surgical procedure calls the clinical facility with complaints of vaginal discharge. What action should the nurse take first? 1. Document the complaint. 2. Notify the healthcare provider. 3. Ask the patient to come to the clinic immediately. 4. Check if the patient has been prescribed an antibiotic. Answer: 1 Explanation: 1. After a laparoscopic surgery, the patient may experience a small amount of vaginal bleeding or discharge. This discharge should be managed with perineal pads. The complaint is normal and should be documented and the patient provided with the needed education. 2. There is no need at this time to contact the physician to report normal findings. 3. There is no need at this time to have the patient seen at the clinic. 4. There is no indication that the patient has an infection. Page Ref: 1755 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

15 ..

16) The nurse provides aftercare teaching to a patient recovering from a colposcopy. Which patient statement indicates an understanding of the information? Select all that apply. 1. "I will need to avoid heavy lifting for the next 4 weeks." 2. "I should douche at the end of 1 week to remove vaginal discharge." 3. "I can take ibuprofen for pain if needed." 4. "I will have some light vaginal discharge." 5. "I will report a temperature elevation to the physician's office." Answer: 3, 4 Explanation: 1. The colposcopy is a minor procedure to manage cervical dysplasia. The procedure is performed in the physician's office. The patient does not need to avoid heavy lifting for weeks. 2. Vaginal discharge is anticipated after the procedure. Perineal pads should be used to manage the discharge. Douching and tampons are to be avoided. 3. The colposcopy is a minor procedure to manage cervical dysplasia. The procedure is performed in the physician's office. The patient may experience some mild discomfort, for which an NSAID such as ibuprofen may be taken. 4. Vaginal discharge is anticipated after the procedure. Perineal pads should be used to manage the discharge. 5. Temperature elevation is not identified as a potential adverse effect from a colposcopy. Page Ref: 1753 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

16 ..

17) A female patient reports the inability to conceive as being because of the spouse's choice of underwear. What should the nurse consider about this patient's statement regarding sperm production? 1. Tight male underwear inhibits sperm production. 2. Tight male underwear impedes blood flow to the penis. 3. Tight underwear may increase heat in the genital area. 4. The patient is repeating an "old wives' tale." Answer: 3 Explanation: 1. Sperm production is not directly related to underwear sizing. 2. Sperm is not produced in the penis. 3. The optimum temperature for sperm production is approximately 2 to 3 degrees below body temperature. 4. There is truth in the patient's statement, so this is not an "old wives' tale." Page Ref: 1741 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.1 Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

17 ..

18) A male patient was born with only one testis. What might be an effect of this anatomical change? 1. May need testosterone replacement therapy 2. May be sterile 3. May need estrogen replacement therapy 4. Will have a normal level of sperm production Answer: 1 Explanation: 1. The testes produce sperm and testosterone. With one testis, there is a reduction in testosterone and sperm production. 2. The patient will not be sterile if the remaining testicle is producing sperm. 3. Estrogen replacement will not be indicated in the absence of a testicle. 4. The level of sperm production is not known without testing. Page Ref: 1741 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.1 Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

18 ..

19) A male patient has an infection of the epididymis. What reduction might occur in the patient's body because of this infection? 1. Testosterone production 2. Mature sperm 3. Blood flow to the penis 4. Ability to sustain an erection Answer: 2 Explanation: 1. An infection in the epididymis does not impact testosterone production. 2. The epididymis is the final area for the storage and maturation of sperm. 3. An infection in the epididymis does not impact blood flow to the penis. 4. An infection in the epididymis does not impact the ability to sustain an erection. Page Ref: 1741 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.1 Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

19 ..

20) The analysis of a patient's semen indicates the patient could have difficulty impregnating his spouse. Which volume of sperm per milliliter does this patient most likely have? 1. 150 million 2. 100 million 3. 50 million 4. 5 million Answer: 4 Explanation: 1. The total ejaculate of a healthy male contains from 20 to 150 million sperm per milliliter. 2. The total ejaculate of a healthy male contains from 20 to 150 million sperm per milliliter. 3. The total ejaculate of a healthy male contains from 20 to 150 million sperm per milliliter. 4. The total ejaculate of a healthy male contains from 20 to 150 million sperm per milliliter. A sperm count of 5 million would likely not result in pregnancy. Page Ref: 1742, 1745 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

20 ..

21) An analysis of a patient's sperm shows the sperm are not developing motility. Which body structure should the nurse suspect is not functioning at the optimal level in this patient? 1. Prostate 2. Epididymis 3. Scrotum 4. Penis Answer: 2 Explanation: 1. The prostate does not play a role in the development of motility of the sperm. 2. The epididymis is the final area for the storage and maturation of sperm. 3. The scrotum does not play a role in the development of motility of the sperm. 4. The penis does not play a role in the development of motility of the sperm. Page Ref: 1741 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.1 Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

21 ..

22) A male patient's PSA (prostate-specific antigen) level is elevated. Which diagnostic test for cancer might be indicated for this patient? 1. Abdominal x-ray 2. Biopsy 3. CT scan 4. Small bowel examination Answer: 2 Explanation: 1. An abdominal x-ray would not definitively diagnose the presence of prostate cancer. 2. Prostate cancer is diagnosed and monitored by measuring prostate-specific antigen (PSA). The prostate may be examined by a prostate biopsy to accurately diagnose cancer. 3. A CT scan would not definitively diagnose the presence of prostate cancer. 4. A small bowel examination would not definitively diagnose the presence of prostate cancer. Page Ref: 1744 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

22 ..

23) A 40-year-old male patient is unable to have an erection since being prescribed an antispasmodic for a muscular back injury and hydrocortisone cream to manage a chronic integumentary condition. What should the nurse suspect this patient is experiencing? 1. Side effect of the antispasmodic medication 2. Age-related erectile dysfunction 3. Side effect of the hydrocortisone cream 4. Result of the muscular back injury Answer: 1 Explanation: 1. Antispasmodic medication may cause problems with sexual function. 2. A male at the age of 40 does not routinely experience erectile dysfunction. 3. Hydrocortisone cream is not identified as a medication that may cause problems with sexual function. 4. There is no indication that the patient has any neurological deficits from the muscular back injury. Page Ref: 1742 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

23 ..

24) The nurse is preparing to examine a male patient's reproductive organs. What should the nurse do in preparation for this examination? Select all that apply. 1. Secure a private examination room. 2. Use clean hands for the examination. 3. Ask the patient to lie down on the examination table. 4. Ask the patient to empty his bladder. 5. Make sure the room temperature is cool. Answer: 1, 4 Explanation: 1. The nurse ensures that the examining room is warm and private. 2. The nurse puts on gloves before beginning and wears them throughout the examination. 3. The assessment may be done with the patient sitting or standing. 4. The patient is asked to empty his bladder, remove his clothing, and put on a gown or drape. 5. A cool temperature may be uncomfortable for the patient who is undressed. Page Ref: 1744 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the male and female reproductive systems.

24 ..

25) A female patient reports experiencing severe menstrual cramps. Which uterine structure should the nurse recognize is responsible for the patient's symptom? 1. Perimetrium 2. Myometrium 3. Endometrium 4. Cervix Answer: 2 Explanation: 1. The perimetrium is a serous layer and does not have muscle that can contract and cause pain. 2. The myometrium is the middle layer and makes up most of the uterine wall. This layer has muscle fibers that run in various directions and allow contractions during menstruation or childbirth and expansion as the fetus grows. 3. The endometrium is the innermost layer that is shed during menstruation and does not have muscle that can contract and cause pain. 4. The cervix is the pathway between the vagina and the uterus and is not the area of muscle contraction that causes menstrual cramps. Page Ref: 1746 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.3 Describe the anatomy, physiology, and functions of the female reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

25 ..

26) A female patient reports using special vitamins to "increase the production of eggs" to aid in conception. How should the nurse interpret this patient's action? 1. Proactive in attempts to become pregnant 2. Will result in improved health 3. Is anxious about nothing 4. Misinformed Answer: 4 Explanation: 1. Special vitamins will not help increase the production of eggs. 2. The use of vitamins may or may not improve health. There is not enough information about the type of vitamins being used. 3. The patient might have other health issues that hinder the ability to become pregnant. 4. The total number of ova is present at birth. The nurse needs to explain this to the patient and then further evaluate the types of vitamins the patient has been taking. The patient might have other health issues that hinder the ability to become pregnant. Page Ref: 1747 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Ante/Intra/Postpartum and Newborn Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

26 ..

27) A young female patient reports having a "thin, runny discharge" from the vagina every month, about halfway through the menstrual cycle. What should the nurse realize this patient is describing? 1. Normal changes in cervical mucus 2. Evidence of a blocked vaginal gland 3. Sexual arousal response 4. Evidence of a sexually transmitted infection Answer: 1 Explanation: 1. In the menstrual cycle, as the maturing follicle begins to produce estrogen around days 6 to 14, the proliferative phase begins. The amount of cervical mucus produced near the time of ovulation increases. Cervical mucus changes to a thin, crystalline substance and forms channels to help the sperm move up into the uterus. 2. Symptoms of a blocked vaginal gland are not evident. 3. This is not an indication of a sexual arousal response. 4. Changes in cervical mucus are not an indication of a sexually transmitted infection. Page Ref: 1747 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.3 Describe the anatomy, physiology, and functions of the female reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

27 ..

28) During an assessment, the patient asks why the "armpit" is being assessed. How should the nurse respond? Select all that apply. 1. "I'm counting the ribs." 2. "Don't you feel your own armpits?" 3. "Breast tissue extends into this area." 4. "I'm assessing hair distribution in this area." 5. "The armpits should be part of a breast self-examination." Answer: 3, 5 Explanation: 1. Counting the ribs is unnecessary. 2. This response does not address the patient's question. 3. The nurse palpates all sections of both axillae for enlarged nodes. 4. Hair distribution would be assessed by visualization, not palpation. 5. The nurse should explain breast self-examination (BSE) to the patient. Page Ref: 1749 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the male and female reproductive systems.

28 ..

29) During an assessment of a female patient's internal genitalia, the nurse feels a bulge along the posterior vaginal wall. What should the nurse suspect is occurring with this patient? 1. Prolapsed uterus 2. Cystocele 3. Rectocele 4. Blocked gland Answer: 3 Explanation: 1. Protrusion of the cervix or uterus into the vagina indicates uterine prolapse. 2. Bulging of the anterior vaginal wall and urinary incontinence indicates a cystocele. 3. Bulging of the posterior wall indicates a rectocele. 4. The vagina does not contain glands but rather is lubricated by mucus-producing cells. Skene's and Bartholin glands are located between the labia in the vestibule. Page Ref: 1751 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

29 ..

30) A female patient is scheduled for an ultrasound to examine the uterus. How should the nurse instruct the patient to prepare for the test? 1. Take a laxative the night before the test to clear the colon of feces. 2. Restrict fluids prior to the day of the test. 3. Take no food or fluids after midnight the day before the test. 4. Increase fluid intake and do not void until after the test. Answer: 4 Explanation: 1. Clearing the colon of feces is not necessary, as the colon does not obstruct the view of the uterus. 2. The patient should not be instructed to restrict fluids. 3. Restricting food intake would not assist in viewing the uterus. 4. For an abdominal ultrasound, the patient should be instructed to increase the intake of fluids and not to void until the test is completed. This ensures a full bladder to lift the pelvic organs higher in the abdomen and improve visualization. Page Ref: 1755 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 4. Recognize the purpose of and related nursing interventions for patients undergoing diagnostic tests for assessment of the male and female reproductive systems.

30 ..

31) An older female patient is experiencing growth of hair on the chin. Which age-related change should the nurse associate with this finding? 1. Increased estrogen production 2. Increased production of luteinizing hormone 3. Decreased estrogen production 4. Decreased production of follicle-stimulating hormone Answer: 3 Explanation: 1. Postmenopausal women experience a reduction in estrogen production. 2. Luteinizing hormone does not affect hair growth in females. 3. The normal reduction in estrogen production associated with aging causes changes throughout the body, including loss of skin tone and growth of facial hair. 4. FSH levels do not influence hair growth. Page Ref: 1756 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Aging Process Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.5 Differentiate considerations for assessing the reproductive systems of older adults and of individuals in the LGBTQI population. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

31 ..

32) During a health history, the nurse becomes concerned that a male patient is at risk for cancer of the reproductive organs. What genetic information about this patient caused the nurse's concern? Select all that apply. 1. The patient's mother has arthritis. 2. The patient's father had prostate cancer. 3. The patient's brother was treated for testicular cancer. 4. The patient was treated for cryptorchidism as a young child. 5. The patient's uncle has been diagnosed with type 2 diabetes mellitus. Answer: 2, 3, 4 Explanation: 1. A family history of arthritis does not increase the patient's risk of developing cancer of the reproductive organs. 2. Several diseases of the male reproductive system have a genetic component. During the health assessment interview, it is especially important to ask about a family history of prostate cancer. Although the exact genetic predisposition in some men for prostate cancer is unknown, many studies have identified a family history as a major risk factor. 3. Several diseases of the male reproductive system have a genetic component. During the health assessment interview, it is especially important to ask about a family history of testicular cancer, which is a risk factor for cancer of the testes. 4. Several diseases of the male reproductive system have a genetic component. During the health assessment interview, it is especially important to ask about a family history of testicular or prostate cancer. Cryptorchidism can be a risk factor for testicular cancer. 5. A family history of type 2 diabetes mellitus does not increase the patient's risk of developing cancer of the reproductive organs. Page Ref: 1742 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.1 Describe the anatomy, physiology, and functions of the male reproductive system, and identify abnormal findings that may indicate impairment of the reproductive system. MNL Learning Outcome: 1. Utilize appropriate techniques to perform a health history and physical assessment of the male and female reproductive systems.

32 ..

33) After genetic testing, it is determined that a male patient is missing the sex-determining region Y gene (SRY). What manifestations should the nurse expect to assess in this patient? Select all that apply. 1. Balanitis 2. Minimal libido 3. Negative sperm production 4. No secondary sex characteristics 5. Changes in bone and muscle structure Answer: 2, 3, 4, 5 Explanation: 1. Balanitis, or inflammation of the glans, is associated with bacterial or fungal infections. 2. Men who are missing the SRY often have altered testicular development. Testosterone, the primary androgen produced by the testes, promotes libido (sexual desire). 3. Men who are missing the SRY often have altered testicular development. Testosterone, the primary androgen produced by the testes, is essential for spermatogenesis. 4. Men who are missing the SRY often have altered testicular development. Testosterone, the primary androgen produced by the testes, is essential for the development and maintenance of secondary sex characteristics. 5. Men who are missing the SRY often have altered testicular development. Testosterone, the primary androgen produced by the testes, promotes the growth of muscles and bone. Page Ref: 1742 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

33 ..

34) A female patient is informed that she has the BRCA1 gene. On which health problems should the nurse focus when assessing this patient? Select all that apply. 1. Asthma 2. Fibromyalgia 3. Heart disease 4. Breast cancer 5. Ovarian cancer Answer: 4, 5 Explanation: 1. Having the BRCA1 gene does not increase a woman's risk of developing asthma. 2. Having the BRCA1 gene does not increase a woman's risk of developing fibromyalgia. 3. Having the BRCA1 gene does not increase a woman's risk of developing heart disease. 4. There is a clear genetic link for some cases of both breast and ovarian cancer. One breast cancer susceptibility gene, BRCA1, increases a woman's risk for having breast cancer at some point in her life. 5. There is a clear genetic link for some cases of both breast and ovarian cancer. One breast cancer susceptibility gene, BRCA1, increases a woman's risk for having ovarian cancer at some point in her life. Page Ref: 1748 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

34 ..

35) The nurse is preparing to assess a female adolescent diagnosed with Turner syndrome. What finding should the nurse expect because of this genetic disorder? Select all that apply. 1. Webbed neck 2. Muscle atrophy 3. Short stature 4. Facial hair growth 5. Lack of sexual development Answer: 1, 3, 5 Explanation: 1. Turner syndrome is a disorder in a female caused by complete or partial absence of one of the two X chromosomes. The disorder is characterized by a webbed neck. 2. Muscle atrophy is not a manifestation of Turner syndrome. 3. Turner syndrome is a disorder in a female caused by complete or partial absence of one of the two X chromosomes. The disorder is characterized by short stature. 4. Facial hair growth is not a manifestation of Turner syndrome. 5. Turner syndrome is a disorder in a female caused by complete or partial absence of one of the two X chromosomes. The disorder is characterized by a lack of sexual development at puberty. Page Ref: 1748 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.4 Outline the components of the assessment of the female reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

35 ..

36) The nurse is concerned that a male patient may have breast cancer. What did the nurse assess to make this clinical decision? Select all that apply. 1. A painless nodule in the testis 2. Enlarged supraventricular nodes 3. Femoral bulge that increases with coughing 4. Tender disk of breast tissue behind the areola 5. Hard, irregular, fixed nodule in the nipple area Answer: 2, 5 Explanation: 1. A painless nodule in the testis is associated with testicular cancer. 2. Enlarged supraclavicular nodes may indicate metastasis. 3. A femoral bulge that increases with coughing or straining suggests a hernia. 4. A tender disk of breast tissue behind the areola indicates gynecomastia. 5. A hard, irregular, fixed nodule in the nipple area suggests carcinoma. Page Ref: 1743 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 47.2 Outline the components of the assessment of the male reproductive system, including topics for the health assessment interview, techniques for physical assessment, and the diagnostic tests used in the assessment. MNL Learning Outcome: 3. Interpret abnormal findings of the male and female reproductive systems collected during assessment.

36 ..

37) The nurse is preparing a teaching tool on testicular self-examination. Which information should the nurse include? Select all that apply. 1. Examine the testicles once a week. 2. Examine while taking a warm shower. 3. Identify the epididymis as soft and tender. 4. Identify the spermatic cord as firm and smooth. 5. Gently roll each testicle between the thumb and fingers. Answer: 2, 3, 4, 5 Explanation: 1. The testicles should be examined once a month. 2. The testicles should be examined when taking a warm shower or bath or just after if a mirror is used to compare the size. 3. The epididymis is just above and behind the testicle and feels soft and tender. 4. The spermatic cord extends up from the epididymis and feels firm and smooth. 5. The testicles should be gently rolled between the thumb and fingers of each hand. Page Ref: 1757 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 47.6 Summarize topics that nurses teach to promote healthy sexuality and reproduction across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

37 ..

38) A patient with osteoarthritis is postmenopausal and is upset because intercourse is uncomfortable. What should the nurse suggest to this patient? Select all that apply. 1. Use a water-soluble vaginal lubricant. 2. Consider estrogen replacement therapy. 3. Engage in intercourse on a regular basis. 4. Adapt the position for intercourse to reduce pain. 5. Accept that sexual intercourse will need to reduced. Answer: 1, 2, 3, 4 Explanation: 1. For problems related to vaginal dryness and dyspareunia, water-soluble vaginal lubricants should be recommended. 2. Estrogen replacement therapy can be suggested for vaginal dryness and dyspareunia. 3. Intercourse on a regular basis can be suggested for vaginal dryness and dyspareunia. 4. Women who experience joint pain or other musculoskeletal pain due to conditions such as arthritis can benefit from instruction on how to adapt positions for intercourse. 5. Aging women should be encouraged to reach optimal sexual functioning. Page Ref: 1757 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 47.6 Summarize topics that nurses teach to promote healthy sexuality and reproduction across the lifespan. MNL Learning Outcome: 2. Recognize normal findings of the male and female reproductive systems collected during assessment and health promotion activities to support the health of these body systems.

38 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 48 Nursing Care of Men with Reproductive System and Breast Disorders 1) A 35-year-old male is concerned about his inability to sustain an erection. What topic should the nurse question the patient about when assessing this health problem? 1. Substance use or abuse 2. Marital status 3. Employment history 4. Education level Answer: 1 Explanation: 1. Most problems with erection are the result of a disease (with a three-times greater incidence in men with diabetes mellitus), injury, or chemical substances (such as prescribed medications, alcohol, nicotine, cocaine, or marijuana) that affect nerve conduction or hormone levels or decrease blood flow in the penis. 2. Marital status is not associated with an inability to sustain an erection. 3. Employment status is not associated with an inability to sustain an erection. 4. Educational level is not associated with an inability to sustain an erection. Page Ref: 1762 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

1 ..

2) A middle-aged patient who takes nitroglycerin for angina asks for a prescription to aid with erectile dysfunction. What should the nurse do in response to this patient's request? 1. Explain why the erectile dysfunction medication is not a good idea with the heart medication. 2. Provide education about the medication once the prescription is provided. 3. Remind the patient to stop taking the heart medication when planning to take the erectile dysfunction medication. 4. Suggest a behavioral health consult to analyze the reason for the erectile dysfunction. Answer: 1 Explanation: 1. The use of medications for erectile dysfunction is contraindicated for the patient who is taking medications used to manage cardiac conditions. 2. Sildenafil (Viagra) and vardenafil (Levitra) should not be taken by men who are also taking nitrate-based drugs. Tadalafil (Cialis) should not be taken if the man is also taking nitrates. 3. Discontinuing cardiac drugs is not advisable. 4. A behavioral health consult would not be the first or primary suggestion in this case as physical issues should be explored. Page Ref: 1763 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

2 ..

3) A male patient with type I diabetes mellitus and coronary artery disease is able to achieve an erection but cannot maintain it. What could be done to assist this patient? 1. Suggest an O ring. 2. Provide tadalafil (Cialis) teaching material. 3. Provide sildenafil (Viagra) teaching material. 4. Discuss penile implant surgery. Answer: 1 Explanation: 1. When managing an erectile dysfunction condition, the least invasive treatments should be employed first. The least invasive measure would be to provide or offer information about the O ring, which is a small band placed on the base of the penis that helps to maintain an erection. 2. Since the patient has coronary artery disease, it is assumed that the patient might be prescribed nitroglycerin for transient chest pain. Erectile dysfunction medications would be contraindicated in this case. 3. Since the patient has coronary artery disease, it is assumed that the patient might be prescribed nitroglycerin for transient chest pain. Erectile dysfunction medications would be contraindicated in this case. 4. Penile implant surgery may not be an option due to this patient's physical health and is an invasive procedure. Other options should be considered first, before surgery is considered. Page Ref: 1763 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

3 ..

4) A female patient asks the nurse for help because her spouse has not been able to attain an erection in several months. What can the nurse do to help this patient? 1. Assess for the most recent sexual practices. 2. Suggest that she seek psychiatric counseling. 3. Suggest that they both see a marriage counselor. 4. Provide a prescription for tadalafil (Cialis). Answer: 1 Explanation: 1. It is essential for healthcare providers to understand the patient and partner's sexual pattern in order to provide appropriate, individualized care. 2. It is premature to suggest marital or psychiatric counseling. 3. It is premature to suggest marital or psychiatric counseling. 4. Prescribing medications is beyond the nurse's scope of practice. Page Ref: 1765 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

4 ..

5) A patient is recovering from a penile implant procedure. What should be included in the care of and teaching about the implant? Select all that apply. 1. Encourage the patient to practice inflating and deflating the device during the recovery period. 2. Suggest wearing snug-fitting underwear and loose-fitting trousers to conceal the semierection. 3. Encourage the patient to resume sexual activity within three weeks. 4. Remind the patient to not inflate or deflate the device for at least four weeks. 5. Suggest wearing loose-fitting underwear and trousers. Answer: 1, 2 Explanation: 1. For a penile implant, teach the patient and his partner how to use the pump, including how to inflate and deflate the device. Suggest that he practice inflation and deflation during the postoperative period. 2. Suggest wearing snug-fitting underwear with the penis placed in an upright position on the abdomen and loose trousers. 3. Provide information about length of healing, and that sexual activity may resume within six to eight weeks following surgery. Recovery from surgery is necessary before resuming sexual activity. 4. Practice using the pump will maintain the pump position and promote tissue growth around the implant. 5. Suggest wearing snug-fitting underwear and loose trousers with the penis placed in an upright position on the abdomen. Page Ref: 1765 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

5 ..

6) A male patient is concerned about ongoing premature ejaculation. What should the nurse do to assist this patient? 1. Suggest that the patient wear a condom with sexual activity. 2. Suggest that the patient talk with the physician about changing prescribed medications. 3. Tell the patient that the condition is temporary and will disappear in time. 4. Review any newly prescribed medications, and check for side effects. Answer: 1 Explanation: 1. Premature ejaculation is very responsive to medical management. The man can experiment with wearing condoms to decrease sensitivity. 2. Premature ejaculation is not a side effect of medications. Premature ejaculation is very responsive to medical management. 3. Using relaxation and guided imagery can delay sexual excitement. Mechanical devices, such as constrictive rings around the base of the penis, can help the man delay ejaculation and sustain an erection. 4. Premature ejaculation is not generally a side effect of medications. Page Ref: 1765 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

6 ..

7) A patient seeks medical attention for an erection that has lasted for more than four hours. What should the nurse include in the patient's assessment? 1. Prescribed medications 2. Substance abuse 3. Blood pressure 4. Number of sexual partners Answer: 1 Explanation: 1. Men who use intracavernous injection therapy or tadalafil (Cialis) for erectile dysfunction are at risk for priapism. 2. Substance abuse assessment would be included in any admission process but does not have a direct influence on the sustained erection. 3. Blood pressure measurements would be included in any admission process but do not have a direct influence on the sustained erection. 4. Number of sexual partners is not related to the problem. Page Ref: 1766 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.2 Describe the pathophysiology and manifestations of disorders of the penis, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

7 ..

8) A patient experiencing a "swollen" scrotum is found to have fluid within the scrotum. Which health problem should the nurse suspect this patient will need to have treated? 1. Hydrocele 2. Spermatocele 3. Varicocele 4. Scrotal cancer Answer: 1 Explanation: 1. A hydrocele, which is the most common cause of scrotal swelling, is a collection of fluid within the tunica vaginalis. A hydrocele may be differentiated from a solid mass by transillumination or ultrasound of the scrotum. 2. A spermatocele is a mobile, usually painless mass that forms when efferent ducts in the epididymis dilate and form a cyst. 3. A varicocele is an abnormal dilation of a vein within the spermatic cord. It is caused by incompetent or congenitally missing valves that allow blood to pool in the spermatic cord veins. The dilated vein forms a soft mass that may be painful. 4. Scrotal cancer would be manifested by a solid mass rather than a fluid-filled area. Page Ref: 1767 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

8 ..

9) A 40-year-old male is diagnosed with epididymitis. What should the nurse consider as being a potential cause of this disorder? Select all that apply. 1. Urinary tract infection 2. Prostatitis 3. Unprotected anal intercourse 4. Gonorrhea 5. Undiagnosed congenital disorder Answer: 1, 2, 3 Explanation: 1. In men older than 35, epididymitis is associated with a urinary tract infection. 2. In men older than 35, epididymitis is associated with prostatitis. 3. Men who practice unprotected anal intercourse may acquire sexually transmitted epididymitis. 4. Urethritis, not epididymitis, would be consistent with gonorrhea. 5. Congenital disorders are not associated with epididymitis. Page Ref: 1768 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

9 ..

10) A patient who is being treated for epididymitis stops taking his antibiotics. Which health problem is this patient at risk for developing? 1. Orchitis 2. Priapism 3. Hydrocele 4. Spermatocele Answer: 1 Explanation: 1. Orchitis is an acute inflammation or infection of the testes. It most commonly occurs as a complication of a systemic illness or as an extension of a genitourinary infection, such as epididymitis. 2. Priapism is a condition of the male reproductive system but it is not associated with the presence of an infectious condition. 3. Hydrocele is a condition of the male reproductive system but it is not associated with the presence of an infectious condition. 4. Spermatocele is a condition of the male reproductive system but it is not associated with the presence of an infectious condition. Page Ref: 1768 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

10 ..

11) A patient experiencing heaviness in the scrotum has a normal dehydrogenase level. What should this information indicate to the nurse? 1. More diagnostic tests for testicular cancer are needed. 2. The patient has testicular cancer. 3. The patient does not have testicular cancer. 4. The patient has a spermatocele. Answer: 1 Explanation: 1. Elevations in serum lactate dehydrogenase levels are associated with the presence of testicular cancer, and may be significantly elevated when metastatic disease is present. This laboratory test is a less specific indicator of testicular cancer than the human chorionic gonadotropin and alpha-fetoprotein. The levels alone are not sufficient to make a diagnosis of cancer and should promote further testing. 2. Elevations in serum lactate dehydrogenase levels are associated with the presence of testicular cancer, and may be significantly elevated when metastatic disease is present. This laboratory test is a less specific indicator of testicular cancer than the human chorionic gonadotropin and alpha-fetoprotein. The levels alone are not sufficient to make a diagnosis of cancer and should promote further testing. 3. Elevations in serum lactate dehydrogenase levels are associated with the presence of testicular cancer, and may be significantly elevated when metastatic disease is present. This laboratory test is a less specific indicator of testicular cancer than the human chorionic gonadotropin and alpha-fetoprotein. The levels alone are not sufficient to make a diagnosis of cancer and should promote further testing. 4. Levels of serum lactate dehydrogenase would not be useful in diagnosis of spermatocele. Page Ref: 1770 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

11 ..

12) A male patient is diagnosed with stage 1 testicular cancer. What should the nurse consider as being the first step in this patient's treatment? 1. Surgical removal of the testicle 2. Aspiration of the enlarged testicle 3. Chemotherapy 4. Radiation Answer: 1 Explanation: 1. Radical orchiectomy is the treatment used in all forms and stages of testicular cancer. 2. Aspiration of the enlarged testicle is not a part of treatment for stage 1 testicular cancer. 3. The type and progression of the disease process will determine whether the patient needs chemotherapy. 4. The type and progression of the disease process will determine whether the patient needs radiation. Page Ref: 1770 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

12 ..

13) A patient is diagnosed with asymptomatic inflammatory prostatitis. In which way was this diagnosis made? 1. After examining tissue from the prostate 2. By testing the serum PSA (prostate-specific antigen) level 3. According to the patient's symptoms 4. After palpating the patient's prostate gland Answer: 2 Explanation: 1. A biopsy is not needed for this health problem. 2. Asymptomatic inflammatory prostatitis is usually diagnosed when the man is undergoing assessment for another issue or during general healthcare screening (such as PSA testing). 3. This health problem is asymptomatic. 4. More than prostate palpation is needed to diagnose asymptomatic inflammatory prostatitis. Page Ref: 1772 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

13 ..

14) The nurse is planning instructions for a patient diagnosed with prostatitis. What should be included in these instructions? Select all that apply. 1. Increase fluid intake up to 3 L per day. 2. Adhere to a daily bowel movement regime. 3. Remind the patient that the condition is not contagious. 4. Only take antibiotics when symptoms are present. 5. Withhold voiding for as long as possible. Answer: 1, 2, 3 Explanation: 1. Teaching for the man with prostatitis focuses on symptom management. Men with acute and chronic bacterial prostatitis should be taught to increase fluid intake to around 3 L daily and to void often. 2. Regular bowel movements help to ease pain associated with defecation. 3. Men with chronic prostatitis/chronic pelvic pain syndrome need to know that the condition is not contagious. 4. It is important to teach the man to finish the course of antibiotic therapy. 5. Men with acute and chronic bacterial prostatitis should be taught to increase fluid intake to around 3 L daily and to void often. Page Ref: 1772 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

14 ..

15) An older male patient complains of problems emptying the bladder, especially at night. Which health problem should the nurse suspect the patient is experiencing? 1. Benign prostatic hyperplasia 2. Urinary tract infection 3. Bladder cancer 4. Testicular cancer Answer: 1 Explanation: 1. Benign prostatic hyperplasia (BPH) begins at 40 to 45 years of age, and continues slowly through the rest of life. It is estimated that more than half of all men over age 60 have BPH. Primary symptoms associated with benign prostatic hypertrophy are associated with voiding and difficulty starting the urine stream, dysuria, and nocturia. 2. Urinary tract infection may share the symptom of dysuria with BPH, but the patient would not have difficulty starting the urine stream. 3. Bladder cancer may also have pain as a symptom, but is also accompanied frequently by hematuria. 4. Testicular cancer would first be manifested by a growth in the testicle. Page Ref: 1773 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

15 ..

16) A patient is diagnosed with benign prostatic hyperplasia. For which reason should this patient's blood pressure be closely monitored? 1. Whether the patient can tolerate doxazosin (Cardura) 2. Whether surgery is indicated 3. The volume of urine being retained in the bladder 4. The dose of finasteride (Proscar) Answer: 1 Explanation: 1. Excessive smooth muscle contraction in benign prostatic hyperplasia (BPH) may be blocked with the alpha-adrenergic antagonists such as doxazosin (Cardura). This medication relieves obstruction and increases the flow of urine. It may cause orthostatic hypotension. 2. The use of surgical intervention to manage BPH is not determined by monitoring blood pressure alone. 3. The volume of urinary residual does not have bearing in this question. 4. Finasteride (Proscar) does not impact blood pressure. Page Ref: 1774 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

16 ..

17) A patient is planning to have surgery for the treatment of benign prostatic hyperplasia. Which procedure should the nurse explain has the fewest postoperative complications? 1. Transurethral needle ablation (TUNA) 2. Transurethral incision of the prostate (TURP) 3. Perineal prostatectomy 4. Suprapubic prostatectomy Answer: 1 Explanation: 1. The transurethral needle ablation (TUNA) system uses low-level radiofrequency through twin needles to burn away a region of the enlarged prostate. Shields protect the urethra. TUNA improves the flow of urine through the urethra and does not cause impotence or incontinence. 2. Transurethral incision of the prostate (TURP) involves the insertion of a surgical instrument and optical device into the urethra to the prostate. Erectile dysfunction is not a common occurrence with this procedure; however, there may be retrograde ejaculation. 3. Perineal prostatectomy removes the gland by way of a perineal incision. This procedure has a high incidence of complications including impotence and rectal injury. 4. The suprapubic prostatectomy utilizes an abdominal incision. It involves greater blood loss and an increased risk of infection. Page Ref: 1774 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Communication and Documentation Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

17 ..

18) The nurse is instructing a patient with benign prostatic hyperplasia about techniques to reduce urinary retention. What should these instructions include? 1. Avoid alcoholic beverages. 2. Encourage ingesting large amounts of fluids at one time. 3. Urinate until all of the urine is drained from the bladder. 4. Over-the-counter cold remedies are permitted with other medications. Answer: 1 Explanation: 1. Patient teaching for urinary retention should include limiting liquids that stimulate voiding, such as coffee and alcoholic beverages. 2. Patient teaching for urinary retention should include avoiding the intake of large volumes of liquid at any one time. 3. Patient teaching for urinary retention should include how to use double-voiding technique. 4. Patient teaching for urinary retention should include the risk of developing urinary retention increases with over-the-counter decongestant medications. Page Ref: 1775 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

18 ..

19) A middle-aged male patient has an abnormal digital rectal examination (DRE) with a PSA (prostate-specific antigen) level of 18 ng/mL. Which diagnostic test might be prescribed for this patient? 1. Transrectal ultrasonography (TRUS) 2. Bone scan 3. MRI 4. CT scan of the spine Answer: 1 Explanation: 1. Transrectal ultrasonography (TRUS) may be used when the digital rectal examination (DRE) is abnormal or if the PSA (prostate-specific antigen) level is elevated. In the TRUS test, a small probe is inserted in the rectum. The probe gives off sound waves that provide a picture of the prostate on a video screen. Guided by this picture, the physician inserts a narrow needle through the rectal wall into the prostate gland, and the needle removes a sample of tissue for examination. 2. The bone scan may be performed at a later date to determine the presence of tumor metastasis. 3. The MRI may be performed at a later date to determine the presence of tumor metastasis. 4. The CT scan may be performed at a later date to determine the presence of tumor metastasis. Page Ref: 1779 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

19 ..

20) A male patient complains of frequently "not being able to hold urine," especially when the bladder is very full or when lifting objects. What should the nurse do to help this patient? Select all that apply. 1. Instruct the patient how to do Kegel exercises. 2. Suggest that the patient ask the physician for medications to control this incontinence. 3. Suggest that the patient restrict fluids. 4. Suggest the patient wear a Texas catheter. 5. Suggest the patient wear adult absorbent briefs. Answer: 1, 4 Explanation: 1. The symptoms being described by the patient are consistent with incontinence. The treatment plan for incontinence should initially begin with the least invasive measures. Kegel exercises can be used to improve tone and eliminate or reduce stress incontinence. 2. The treatment plan for incontinence should initially begin with the least invasive measures. 3. Restricting fluids will not decrease incontinence. 4. A Texas catheter is noninvasive and usually suggested for full incontinence. It may improve the patient's self-esteem and allow him to return to regular activities. 5. The use of adult absorbent briefs can be embarrassing to the patient, are recommended for patients who are unable to control their bladders, have problems with mobility, or are bedridden. Page Ref: 1782-1783 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

20 ..

21) A male patient is concerned about a recent increase in breast tissue. What should the nurse do to assist this patient? 1. Review the patient's health history. 2. Tell him that it is self-limiting and will go away in time. 3. Suggest that the patient have a mammogram to ensure he does not have breast cancer. 4. Recommend a breast biopsy to find out the reason for the increase in breast tissue. Answer: 1 Explanation: 1. Any condition that increases estrogen activity or decreases testosterone production can contribute to gynecomastia. Conditions that increase estrogen activity include obesity, testicular tumors, liver disease, and adrenal carcinoma; conditions that decrease testosterone production include chronic illness such as tuberculosis or Hodgkin disease, injury, and orchitis. Drugs such as digitalis, opiates, and chemotherapeutic agents are also associated with gynecomastia. 2. Dismissing the patient's concerns is not therapeutic and, until further evaluation is completed, could be potentially dangerous. 3. Gynecomastia is usually bilateral. If it is unilateral, biopsy may be necessary to rule out breast cancer. 4. Gynecomastia is usually bilateral. If it is unilateral, biopsy may be necessary to rule out breast cancer. Page Ref: 1785 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.5 Describe the pathophysiology and manifestations of disorders of the breast, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

21 ..

22) During a health history interview, the nurse learns that a patient is experiencing recentonset impotence. Which question is most appropriate for the nurse to ask to identify a potential cause of the manifestation? 1. "For what disorders have you been treated in the past? 2. "Does this occur often?" 3. "How does your partner feel about this problem?" 4. "Are you on any medications? Answer: 1 Explanation: 1. Nurses in any healthcare setting may encounter men with ED, either through routine examinations or through assessment of patients' conditions and treatments that may incidentally cause ED. A patient's health history can provide clues to the underlying cause of impotence. 2. Open-ended questions will elicit the most information. Determining the frequency of impotence is important, but a closed question will limit the amount of information obtained. 3. The patient's partner is important, but is not the primary focus of this question. 4. The patient should be asked to list any medications being taken; however, this question is closed and will provide limited information. Page Ref: 1764 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

22 ..

23) The nurse is caring for a patient recovering from prostate surgery. Which action should the nurse take if the patient's urine in the urinary irrigation drainage bag is very dark red? Select all that apply. 1. Check for catheter occlusion. 2. Increase the flow rate of irrigant solution. 3. Check vital signs. 4. Ask the patient to drink more oral fluids. 5. Assess the patient for hyponatremia. Answer: 1, 2 Explanation: 1. Following prostatectomy, urine should appear light pink to clear with an occasional blood clot. If the urine appears very dark red, this may indicate increased venous bleeding or inadequate urine dilution. The catheter is at risk for being occluded and should be checked first. 2. If the man has continuous bladder irrigation (CBI), assess the catheter and the drainage tubing at regular intervals. Maintain the rate of flow of irrigating fluid to keep the output light pink or colorless. 3. Checking vital signs is important but not specific to this situation. 4. Asking the patient to increase fluid intake may increase urine output and assist in diluting the urine, but this may take several hours. 5. Assessing for hyponatremia is a nursing action to detect absorption of bladder irrigation solution. Page Ref: 1775 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

23 ..

24) A patient recovering from prostate surgery is being discharged. What should the nurse include in this patient's instructions? Select all that apply. 1. Do not drive for two weeks. 2. Sexual intercourse should not occur for six weeks. 3. Call the physician if the scrotum becomes swollen and tender. 4. Take aspirin or NSAIDs for discomfort. 5. You may return to work in two weeks. Answer: 1, 2, 3 Explanation: 1. Discharge teaching following prostate surgery should include instructions to avoid driving for two weeks, except for short rides. 2. Discharge teaching following prostate surgery should include instructions to avoid sexual intercourse for six weeks to avoid bleeding. 3. Discharge teaching following prostate surgery should include instructions to call the physician if the scrotum becomes swollen and tender. 4. NSAIDs and aspirin should be avoided for at least two weeks. 5. The patient may return to work after four weeks if the work is not strenuous; otherwise, the patient should wait six to eight weeks. Page Ref: 1776 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

24 ..

25) The nurse is completing the health history of a patient with documented androgen deficiency and erectile dysfunction (ED). Which patient response would be a contraindication for this patient's use of hormone replacement therapy to treat his ED? 1. "I am being treated for prostate cancer." 2. "I hate the idea of having an injection directly in my penis." 3. "I am currently taking antibiotics." 4. "Yes, I have a lot of hair on my chest and probably can't wear a patch." Answer: 1 Explanation: 1. Hormone replacement therapy (HRT) to treat ED may be used for men with documented androgen deficiency who do not have prostate cancer. 2. Hormone replacement therapy (HRT) is via intramuscular injections or topical patches, not intrapenile injections. This response does not relate to contraindications of HRT. 3. Antibiotics are not a contraindication to hormone replacement therapy (HRT). 4. Excessive chest hair is not a contraindication. The patient may place the patch on an area other than the chest or hair that could be removed to permit adherence of the patch. Page Ref: 1763 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

25 ..

26) The nurse is placing an indwelling urinary catheter in an uncircumcised male patient. For which reason should the nurse replace the foreskin after insertion? 1. Paraphimosis may occur as a result of long-term retraction of the foreskin causing ischemia of the glans. 2. Phimosis may occur due to chronic infections and adhesions under the foreskin which results in constriction of the foreskin. 3. Priapism may occur as a result of impaired blood flow in the penis. 4. Replacement of the foreskin prevents malignant changes of the penis. Answer: 1 Explanation: 1. Paraphimosis may occur as a result of long-term retraction of the foreskin, which can result in ischemia of the glans. 2. The foreskin may not be retracted in the patient with phimosis due to the constriction resulting from chronic infections and adhesions and the nurse should not attempt this action during catheterization. 3. Priapism occurs with sustained painful erections, which impair blood flow in the penis, and does not involve the foreskin. 4. Phimosis or the presence of the foreskin can prevent adequate hygiene, which may lead to malignant changes of the penis. Page Ref: 1766 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.2 Describe the pathophysiology and manifestations of disorders of the penis, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

26 ..

27) The nurse is concerned that a patient is at risk for developing cancer of the penis. What did the nurse assess to make this clinical determination? Select all that apply. 1. Phimosis 2. Human papilloma virus (HPV) 3. HIV infection 4. Excessive ultraviolet light exposure 5. Being Jewish or Muslim Answer: 1, 2, 3, 4 Explanation: 1. Cancer of the penis is rare in North America, but risk factors include the presence of phimosis. 2. Cancer of the penis is rare in North America, but risk factors include the presence of HPV. 3. Cancer of the penis is rare in North America, but risk factors include HIV. 4. Cancer of the penis is rare in North America, but risk factors include ultraviolet light exposure, such as used to treat psoriasis. 5. There is no information to support the incidence of penile cancer in Jewish and Muslim men. Page Ref: 1766 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.2 Describe the pathophysiology and manifestations of disorders of the penis, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

27 ..

28) The patient undergoing brachytherapy for prostate cancer is being given instructions for home care. Which patient statement indicates a need for clarification? 1. "It will be nice to sleep in the same bed as my partner." 2. "Guess I'll have to go buy a box of condoms." 3. "I'll be disappointed about not seeing my grandkids." 4. "I'll make an appointment for my next PSA examination." Answer: 1 Explanation: 1. Patients receiving brachytherapy should be instructed to sleep alone. 2. Patients receiving radiation therapy should be instructed to use condoms during sexual activity. 3. Patients receiving brachytherapy should be instructed to avoid close contact with pregnant women, infants, and children. 4. The importance of keeping appointments for yearly PSA examinations should be included. Page Ref: 1784 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

28 ..

29) The spouse of a patient with prostate cancer asks what a stage I tumor means. What is the most appropriate response by the nurse? 1. "Stage I means the cancer involves only the prostate, and surgery and radiation treatments are usually needed." 2. "Staging involves a definition of the type of tumor and the treatment plan." 3. "Did your spouse report having a stage I tumor?" 4. "Let's wait until the doctor comes, and you can talk with him." Answer: 1 Explanation: 1. Grading and staging help determine prognosis and guide treatment decisions. A stage I cancer is confined to the prostate, and treatment will focus on radiation therapy and surgery. 2. Explaining what staging means does not answer the question. 3. The nurse should not ask the spouse about something that is already known. 4. Waiting for the healthcare provider does not answer the question or offer reassurance and could increase the spouse's anxiety. Page Ref: 1780 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for men with reproductive system and breast disorders.

29 ..

30) The nurse is caring for a patient who had a prostatectomy and is now having bladder spasms. What action should the nurse take? Select all that apply. 1. Administer belladonna and opium (B&O) suppositories as prescribed. 2. Check to see if the urinary catheter is draining. 3. Ask the patient if he feels the need to have a bowel movement. 4. Increase the rate of flow of urinary catheter irrigation solution. 5. Assess the patient's temperature. Answer: 1, 2, 3 Explanation: 1. Bladder spasms are one of the three types of pain following prostatectomy, and belladonna and opium (B&O) suppositories may be used to relieve bladder spasms. 2. The presence of a urinary catheter will stimulate the urge to void and bladder spasms. If the catheter becomes kinked and urine fills the bladder, the patient may feel the urge to void and strain, which induces spasms. 3. Straining to have a bowel movement may stimulate bladder spasms. 4. Increasing the flow rate of urinary catheter irrigation solution will have no effect on bladder spasms. 5. Assessing the patient's temperature is important but not related to bladder spasm. Page Ref: 1775 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

30 ..

31) After prostate surgery, a patient is being discharged with an indwelling urinary catheter in place. What teaching should the nurse provide to this patient? Select all that apply. 1. Use the larger urinary drainage bag at night. 2. Keep the larger urinary drainage bag at a level that permits gravity drainage. 3. Do not strap the leg bag too tightly. 4. Place a soft cloth between the leg bag and the skin. 5. Empty the leg bag at least twice a day. Answer: 1, 2, 3, 4 Explanation: 1. Teaching for the patient who is going home with an indwelling urinary catheter should include using the larger urinary drainage bag at night. 2. Teaching for the patient who is going home with an indwelling urinary catheter should include using the larger urinary drainage bag at night and hanging it on the bed frame to permit gravity drainage. 3. Teaching for the patient who is going home with an indwelling urinary catheter should include avoiding strapping the leg bag too tightly to prevent decreased venous return. 4. Teaching the patient who is going home with an indwelling urinary catheter should include placing a soft cloth between the leg bag and the skin to prevent skin irritation. 5. Teaching the patient who is going home with an indwelling urinary catheter should include emptying the leg bag every three to four hours during waking hours to prevent overfilling. Page Ref: 1778 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

31 ..

32) The nurse is caring for a male patient with breast cancer. Which information should the nurse consider when planning care for this patient? 1. Caring for the man with breast cancer is essentially the same as for the woman with breast cancer. 2. Most issues are the same for men and women, but males do not die from the disease. 3. There are different types of breast cancers between men than women. 4. The treatments are different between men and women. Answer: 1 Explanation: 1. Nursing care for the man with breast cancer is essentially the same as for the woman with breast cancer. Psychosocial concerns, embarrassment or shame about his condition, fear about the life-threatening aspect of the disease, and family concerns should be addressed to help the patient and family move toward healing. 2. Because many men believe breast cancer is a woman's disease, they often delay seeking medical attention and may present with more advanced disease. 3. Male breast cancer is clinically and histologically similar to female breast cancer. 4. Treatment of male breast cancer is much the same as for women. Page Ref: 1785 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.5 Describe the pathophysiology and manifestations of disorders of the breast, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

32 ..

33) The spouse of a patient scheduled for a radical prostatectomy asks if the surgery will affect "their sex life." What is the nurse's most appropriate response? 1. "The incidence of sexual dysfunction varies considerably among patients having this surgery." 2. "No, it shouldn't, but you need to talk to the surgeon." 3. "I can't answer any of your questions without first talking to the patient." 4. "Don't worry; the hospital staff will review everything with you the morning of the surgery." Answer: 1 Explanation: 1. Surgical treatment of prostate disorders may cause ED and changes in ejaculatory function. Hormone therapy, a possible diagnosis of cancer, body image changes, fear of the effects of treatment on sexual health and reactions to the surgery are all important considerations and may affect sexual performance. It is important to know the patient's pretreatment sexual function, teach about the effects of therapy on sexual function, and offer the opportunity for the patient and his partner to discuss their concerns about sexual health. 2. The nurse cannot know if sexual health will be affected. 3. This response does not address the spouse's concerns. 4. Addressing the spouse's concerns should not be delayed. Page Ref: 1781 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

33 ..

34) A male patient who was recently diagnosed with hypertension reports not taking the prescribed antihypertensive medication because of how it made him feel. What should the nurse respond to this patient? 1. "Many male patients experience side effects of this drug, which include altered libido and impotence. This is common. Tell me how you felt when you took the drug." 2. "You shouldn't stop taking the drug without first talking to the doctor!" 3. Write a note in the patient's record but say nothing to the patient. 4. "I'm going to give you some information about this medication for you to take home and read. At your next visit, I'll have the doctor talk to you about it." Answer: 1 Explanation: 1. Antihypertensive drugs are a common cause of erectile dysfunction (ED) and loss of libido, and many men do not report the disorder. The side effects should be discussed at the time the prescription is given and reviewed at any follow-up visits. Offering an opening to discuss sexual dysfunction is relevant. 2. Admonishing a patient for not taking medications does not address the problem. 3. Merely noting the issue in the patient's chart does not address the problem. 4. Offering factual information is relevant, but in this case the patient's hypertension remains untreated. Page Ref: 1762 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Communication and Documentation Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

34 ..

35) A patient with repeated bouts of epididymitis is adamant that prescribed medication is always taken. What additional question should the nurse ask to determine possible causes of epididymitis? Select all that apply. 1. "Are you sexually active?" 2. "Do you use condoms?" 3. "Do you practice unprotected anal intercourse?" 4. "Do you do any heavy lifting?" 5. "Do you use any drugs or alcohol?" Answer: 1, 2, 3, 4 Explanation: 1. Epididymitis is more often seen in sexually active men who are less than 35 years of age. 2. Sexually transmitted urethritis is usually the precipitating factor for epididymitis in younger men. 3. Unprotected anal intercourse is a cause of epididymitis. 4. Chemical epididymitis may be the problem due to reflux of urine into the ejaculatory ducts with increased abdominal pressure from excessive heavy lifting. 5. Drugs and alcohol are not specific causes of epididymitis. Page Ref: 1768 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

35 ..

36) A patient is diagnosed with priapism. What should the nurse include in the plan of care for this patient? Select all that apply. 1. Assess the penis to include color changes and degree of erection. 2. Palpate the penis for firmness and rigidity. 3. Administer analgesics as prescribed for pain. 4. Administer iced saline enemas as prescribed. 5. Push oral fluids. Answer: 1, 2, 3, 4 Explanation: 1. Priapism is an involuntary, sustained, painful erection that is not associated with sexual arousal. Impaired blood flow results in ischemia. The nurse will assess the penis for color changes and degree of erection. 2. The nurse will palpate for firmness and rigidity. 3. Analgesics are given for pain control. 4. Iced saline enemas induce anesthesia. 5. Intake and output should be monitored as acute urinary retention can occur. Excessive oral intake would be inappropriate. Page Ref: 1766 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 48.2 Describe the pathophysiology and manifestations of disorders of the penis, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for men with reproductive system and breast disorders.

36 ..

37) The nurse is completing a health history with a male patient and decides to include an assessment of the patient's sexual history for potential erectile dysfunction. What information in the history caused the nurse to make this decision? Select all that apply. 1. Brother treated for testicular cancer 2. Hip replacement surgery 6 months ago 3. Aortic aneurysm repair 2 years ago 4. Acetaminophen (Tylenol) for arthritis pain 5. Coronary artery bypass surgery 10 years ago Answer: 3, 5 Explanation: 1. A family history of testicular cancer will not increase the patient's risk for erectile dysfunction. 2. Hip replacement surgery is not implicated as a cause for erectile dysfunction. 3. A vascular disorder is identified as a potential cause for erectile dysfunction. 4. Acetaminophen (Tylenol) is not implicated as a cause for erectile dysfunction. 5. A vascular disorder is identified as a potential cause for erectile dysfunction. Page Ref: 1762 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

37 ..

38) A male patient is concerned about the inability to ejaculate during sexual intercourse. What information in the patient's medical record should the nurse use to help determine the cause for the patient's health problem? Select all that apply. 1. Medication for hypertension 2. Medication for anxiety 3. Treatment for bipolar disorder 4. Topical steroid for psoriasis 5. Narcotic for chronic back pain Answer: 1, 2, 3, 5 Explanation: 1. The inability to ejaculate may be caused by certain medications such as antihypertensives. 2. The inability to ejaculate may be caused by certain medications such as anxiolytics. 3. The inability to ejaculate may be caused by certain medications such as antidepressants. 4. Topical steroids are not identified as affecting ejaculation. 5. The inability to ejaculate may be caused by certain medications, such as narcotics. Page Ref: 1765 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.1 Describe the pathophysiology and manifestations of male sexual dysfunction, and outline the interprofessional care and nursing care of patients with erectile dysfunction. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

38 ..

39) While reviewing data collected during a health fair, the nurse determines that a male community member should be evaluated for testicular cancer. What risk factor did the patient identify that caused the nurse to make this recommendation? Select all that apply. 1. 30 years old 2. Testicular cancer in father 3. Cryptorchidism at birth 4. Hypertension treatment 5. Two beers daily Answer: 1, 2, 3 Explanation: 1. Risk factors for testicular cancer include age because it is the most common cancer in men between the ages of 13 and 35. 2. Risk factors for testicular cancer include a family history of testicular cancer. 3. Risk factors for testicular cancer include cryptorchidism. 4. Treatment for hypertension is not a risk factor for testicular cancer. 5. Alcohol intake is not a risk factor for testicular cancer. Page Ref: 1769 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 48.3 Describe the pathophysiology and manifestations of disorders of the testis and scrotum, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

39 ..

40) A patient is prescribed pain medication to assist in the treatment of bacterial prostatitis. What additional nonpharmacological intervention should the nurse suggest to the patient to help control the pain of this health problem? Select all that apply. 1. Warm bath 2. Avoiding sitting 3. Taking a walk 4. Stress-reduction activities 5. Applying ice to the rectal area Answer: 1, 2, 4 Explanation: 1. When pain is most severe with bacterial prostatitis, warm baths have been reported to assist in pain reduction. 2. When pain is most severe with bacterial prostatitis, avoidance of sitting has been reported to assist in pain reduction. 3. Walking is not identified as a way to reduce the pain associated with bacterial prostatitis. 4. When pain is most severe with bacterial prostatitis, stress-reducing activities have been reported to assist in pain reduction. 5. Application of ice to the rectal area is not identified as a way to reduce the pain associated with bacterial prostatitis. Page Ref: 1772 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for men with reproductive system and breast disorders.

40 ..

41) During a health interview, a male patient expresses the desire to avoid developing prostate cancer with aging. What should the nurse recommend to reduce this patient's risk factors for the health problem? Select all that apply. 1. Avoiding vasectomy 2. Reducing the intake of animal fat 3. Increasing the intake of vitamin C 4. Restricting exposure to spermicides 5. Taking vitamin A supplements Answer: 1, 2, 5 Explanation: 1. Risk factors for prostate cancer include having a vasectomy because it is believed to increase the levels of circulating free testosterone. 2. A diet high in animal fat is believed to increase the risk for prostate cancer. 3. Vitamin C does not impact the risk for prostate cancer. 4. Spermicides are not identified as increasing the risk for prostate cancer. 5. Excessive supplemental vitamin A is believed to increase the risk for prostate cancer. Page Ref: 1779 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 48.4 Describe the pathophysiology and manifestations of disorders of the prostate gland, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for men with reproductive system and breast disorders.

41 ..

LeMone & Burke's Medical-Surgical Nursing, 7e (Bauldoff/Gubrud/Carno) Chapter 49 Nursing Care of Women with Reproductive System and Breast Disorders 1) A female patient is concerned that a personal relationship will end because of a loss of interest in sex. Which would be an appropriate response for the nurse to make to this patient? 1. "I'm sure it's nothing and will go away in time." 2. "There are other activities you and your partner can do together." 3. "Sex isn't that important in a relationship anyway." 4. "Let's talk more about how you are feeling right now." Answer: 4 Explanation: 1. The nurse does not know that the problem is nothing and will go away. 2. This response does not address the patient's concern about declining sexual desire. 3. Advising the patient that sex is not important in a relationship is imposing a personal belief on the patient. 4. This patient is explaining inhibited sexual desire, which can have physiological or psychological causes. The nurse should not discount the patient's feelings but rather encourage more communication about the situation. Page Ref: 1791 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Therapeutic Communication Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the patient and the patient's support network | NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions | Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 49.1 Describe the pathophysiology and manifestations of disorders of female sexual function, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for women with reproductive system and breast disorders.

1 ..

2) A middle-aged female patient reports constant anxiety, inability to sleep, and headaches. Which health problem should the nurse suspect this patient is experiencing? 1. Amenorrhea 2. Perimenopause 3. Postmenopause 4. Dysmenorrhea Answer: 2 Explanation: 1. Amenorrhea is the absence of menstruation. The patient did not report having an absence of menstruation. 2. Psychologic symptoms of perimenopause include anxiety, inability to sleep, and headaches. 3. The postmenopausal period begins one year after the final menstrual period. No information is given in the question about menstrual flow. 4. Dysmenorrhea is pain or discomfort associated with menstruation. Page Ref: 1798 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.3 Describe the pathophysiology and manifestations of perimenopause, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for women with reproductive system and breast disorders.

2 ..

3) A female patient who is experiencing menopause is "tired of the night sweats." What should the nurse suggest to help this patient? 1. Ensure that the bedroom temperature is cool, and limit sleeping attire. 2. Reduce intake of milk and milk products. 3. Talk with the physician about a hysterectomy. 4. Exercise 1 hour before going to sleep. Answer: 1 Explanation: 1. The underlying cause of hot flashes is not known; however, many physiologic effects of menopause are responsive to nonpharmacologic methods of relief, such as lifestyle changes. 2. The recommended daily intake of calcium for women over 50 is 1200 mg. 3. Encouraging the patient to look into surgical intervention is outside the scope of nursing practice. A hysterectomy would further reduce the patient's natural estrogen levels. 4. Weight-bearing exercise is recommended to reduce the rate of bone loss, help maintain optimum weight, and reduce cardiovascular risk, not to induce sleep and relieve night sweats. Page Ref: 1800 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.3 Describe the pathophysiology and manifestations of perimenopause, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 4. Determine appropriate nursing interventions for women with reproductive system and breast disorders.

3 ..

4) A female patient is experiencing increasing premenstrual symptoms over the past few years and thinks "something must be wrong." What should the nurse suspect is occurring with this patient? 1. Early menopausal symptoms 2. Premenstrual dysphoric disorder 3. Interpersonal relationship difficulties 4. Normal pattern of premenstrual syndrome Answer: 4 Explanation: 1. The manifestations being exhibited are not consistent with menopausal symptoms. 2. Premenstrual dysphoric disorder is PMS of such severity that it has a psychiatric label. This severe form of PMS affects a small number of women and is not indicated by the patient's complaints. 3. There are no indications of interpersonal relationship concerns. 4. Premenstrual syndrome (PMS) is seen less frequently during the teens and 20s and reaches a peak in the mid-30s. Major life stressors, age greater than 30, and depression are risk factors associated with PMS. Page Ref: 1791 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for women with reproductive system and breast disorders.

4 ..

5) The nurse is assisting a patient with ways to reduce the severity of the monthly discomfort associated with premenstrual syndrome. What information should the nurse review with this patient? Select all that apply. 1. Apply ice packs to the lower abdominal region. 2. Practice abdominal breathing. 3. Balance exercise with rest. 4. Increase sodium intake. 5. Restrict caffeine intake. Answer: 2, 3, 5 Explanation: 1. Heat, not ice, relieves muscle spasms and dilates blood vessels, which increases the blood supply to the pelvis and uterine muscles. 2. Techniques for relaxation and stress management include deep abdominal breathing. 3. Exercise is beneficial, but rest is also necessary. 4. Sodium should be restricted to minimize fluid retention. 5. Caffeine restriction reduces irritability. Page Ref: 1791, 1793 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Basic Care and Comfort Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for women with reproductive system and breast disorders.

5 ..

6) A patient is scheduled for an endometrial ablation for extreme uterine bleeding. Which patient statement indicates understanding of the long-term effects of this treatment? 1. "My future menstrual cycles will be normal." 2. "My menstrual cycles will be irregular from now on." 3. "I will stop menstruating and I can't get pregnant now." 4. "I will need hormone replacement therapy to regulate my menstrual cycles." Answer: 3 Explanation: 1. This procedure ends menstruation. 2. This procedure usually produces amenorrhea. 3. In an endometrial ablation, the endometrial layer of the uterus is permanently destroyed using laser surgery or electrosurgical resection. It is performed in women for whom childbearing has been completed and who do not respond to pharmacologic management or D&C. The procedure usually produces amenorrhea. 4. Hormone replacement is not needed after this procedure. Page Ref: 1796 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions | NLN Competencies: RelationshipCentered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Evaluation/Teaching/Learning Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

6 ..

7) A patient is diagnosed with uterine prolapse into the vagina. Which factor should the nurse consider that likely contributed to this disorder? 1. Multiple pregnancies 2. Endometriosis 3. Pelvic inflammatory disease 4. Cervical tumor Answer: 1 Explanation: 1. Downward displacement of the pelvic organs into the vagina results from weakened pelvic musculature, which is usually attributed to stretching of the supporting ligaments and muscles during pregnancy and childbirth. Unrepaired lacerations from childbirth, rapid deliveries, multiple pregnancies, congenital weakness, or loss of elasticity and muscle tone with aging may contribute to these disorders. 2. Endometriosis does not typically cause uterine prolapse. 3. Pelvic inflammatory disease does not typically cause uterine prolapse. 4. Tumors do not typically cause uterine prolapse. Page Ref: 1801 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.4 Describe the pathophysiology and manifestations of structural disorders of the female reproductive system, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for women with reproductive system and breast disorders.

7 ..

8) A female patient is diagnosed with "chocolate" cysts. Which should the nurse consider as the reason for these cysts? 1. Pelvic inflammatory disease 2. Use of oral contraceptives 3. Endometrial overgrowth 4. Hormone imbalance Answer: 3 Explanation: 1. These cysts are not associated with pelvic inflammatory disease. 2. These cysts are not associated with use of oral contraceptives. 3. Endometrial cysts are caused by endometrial overgrowth and are often filled with old blood, which leads to the name "chocolate cysts." Endometrial cysts are the result of endometrial implants on the ovary and are associated with endometriosis. 4. These cysts are not associated with hormone imbalance. Page Ref: 1804 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Physiological Adaptation Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for women with reproductive system and breast disorders.

8 ..

9) A female patient of childbearing age is diagnosed with large uterine fibroids. What should the nurse expect the treatment of choice would be for this patient? 1. Oral contraceptives 2. Estrogen replacement 3. Iron replacement therapy 4. Leuprolide acetate (Lupron) Answer: 4 Explanation: 1. The use of oral contraceptives may reduce heavy bleeding. 2. Medications that stop ovarian production of estrogen and progesterone (hormones necessary for fibroid growth) may provide a temporary decrease in manifestations. 3. Iron replacement therapy is not appropriate for this patient. 4. Leuprolide acetate (Lupron) is used to reduce bleeding and shrinks the fibroids. Page Ref: 1805 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

9 ..

10) A 25-year-old female is diagnosed with endometriosis. What should the nurse include when teaching the patient about this disorder? Select all that apply. 1. Endometriosis can be treated without any long-term effects. 2. If the woman desires children, she should be encouraged to become pregnant before the disease progresses. 3. Laser ablation and birth control pills are the treatments for this condition. 4. Leaving the condition untreated will not result in any long-term health issues. 5. Dyspareunia can occur. Answer: 2, 3, 5 Explanation: 1. Management of endometriosis may include drug (birth control pills) or surgical (laparoscopy and laser ablation) intervention; however, these treatments do have long-term effects. 2. Endometriosis is a slowly progressive disease that is responsive to ovarian hormone stimulation. Because progressive scarring may interfere with the ability to conceive, women with significant endometriosis are encouraged to have children early if they wish to do so. 3. Endometriosis is a slowly progressive disease that is responsive to ovarian hormone stimulation. Management of endometriosis may include drug (birth control pills) or surgical (laparoscopy and laser ablation) intervention. 4. Patients with endometriosis may experience painful, lengthy, or heavy menstrual periods, which constitute health issues for the patient. 5. Dyspareunia (painful intercourse) is a manifestation of endometriosis. Page Ref: 1806 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for women with reproductive system and breast disorders.

10 ..

11) A postmenopausal patient is diagnosed with cervical dysplasia caused by the human papillomavirus. For which procedure that would both diagnose and treat the dysplasia should the nurse prepare this patient? 1. Pap smear 2. Colposcopy 3. Cervical biopsy 4. Loop diathermy Answer: 4 Explanation: 1. Pap smears are used to diagnose cervical dysplasia. This is a diagnostic test not used to manage conditions. 2. Colposcopy is a diagnostic test not used to manage conditions. 3. A cervical biopsy is a diagnostic test not used to manage conditions. 4. A loop diathermy technique or loop electrosurgical excision procedure (LEEP) allows simultaneous diagnosis and treatment of dysplastic lesions found on colposcopy. This procedure is performed in the office and uses a wire for both cutting and coagulation during excision of the dysplastic region of the cervix. Page Ref: 1808-1809 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

11 ..

12) A female patient is experiencing a recurrence of endometrial cancer. Which treatment should the nurse expect to be prescribed for this patient? Select all that apply. 1. Radiation therapy 2. Hormone therapy 3. Partial abdominal hysterectomy 4. Chemotherapy 5. Endometrial ablation Answer: 1, 2, 4 Explanation: 1. Treatment with external and internal radiation may be performed as adjuvant treatment in advanced cases. 2. Hormone therapy may include progestins, antiestrogrens, gonadotropin-releasing hormone agonists, or aromatase inhibitors. 3. A total abdominal hysterectomy and bilateral salpingo-oophorectomy is the surgery performed for stage I cancer. 4. A combination of drugs may be used to treat endometrial cancer, including doxorubicin (Adriamycin), cisplatin, carboplatin, and paclitaxel (Taxol). 5. Endometrial ablation is not sufficient to treat this condition. Page Ref: 1812-1813 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

12 ..

13) A patient recovering from a complete hysterectomy for endometrial cancer is concerned about having sexual encounters because of activity intolerance. What should the nurse suggest to assist this patient? 1. The patient should engage in other activities. 2. The patient should discuss fears with a counselor. 3. The patient should be thankful for surviving cancer surgery. 4. The patient can coordinate sexual activity with rest periods and pain-free periods. Answer: 4 Explanation: 1. The patient is expressing concern regarding sexual activity. 2. The patient is expressing concerns and should have questions addressed before considering a mental health professional. 3. The patient has not expressed concern over survival. 4. Altered sexuality may result from a feeling of unattractiveness, fatigue, or pain and discomfort. The nurse should suggest exploring alternative sexual positions and coordinate sexual activity with rest periods and periods that are relatively free from pain. This creates a more favorable environment for satisfying sexual activity. Page Ref: 1814 Cognitive Level: Applying Client Need & Sub: Psychosocial Integrity: Coping Mechanisms Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.5. Deliver compassionate, patientcentered, evidence-based care that respects patient and family preferences | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Caring Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for women with reproductive system and breast disorders.

13 ..

14) A female patient is concerned about developing ovarian cancer because a greatgrandmother had the disease. Which information from the patient's health history will help reduce the risk for this patient? 1. The patient began her menses at age 10. 2. The patient has never had long-term antibiotic therapy. 3. The patient had her first child at the age of 20. 4. The patient has asymptomatic menstrual cycles. Answer: 3 Explanation: 1. Early menarche is not considered a risk factor for ovarian cancer. 2. Antibiotic therapy is not a risk factor for ovarian cancer. 3. There is about a four-fold increase in risk for ovarian cancer in women who have a firstdegree relative with it. Protective factors include having a child before the age of 25. 4. Asymptomatic menstrual periods are not associated with ovarian cancer. Page Ref: 1814 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Screening Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for women with reproductive system and breast disorders.

14 ..

15) A patient who was recently diagnosed with ovarian cancer wants to have children. Which type of treatment should the nurse expect to be prescribed first for this patient? 1. Chemotherapy 2. Radiation therapy 3. Surgery to remove one ovary 4. Hormone replacement therapy Answer: 3 Explanation: 1. Chemotherapy is used after surgery in the treatment of ovarian cancer. 2. Radiation therapy using external-beam or intracavitary implants is performed for palliative purposes only and is directed at shrinking the tumor at selected sites. 3. In young women with stage I disease who wish to have children, treatment may be limited to removal of one ovary. 4. Hormone therapy is not used to treat ovarian cancer. Page Ref: 1815 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.5 Describe the pathophysiology and manifestations of disorders of female reproductive tissue, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

15 ..

16) A mass is found on a mammogram of a 42-year-old female patient and a cyst is confirmed by an ultrasound of the breast. Which should the nurse expect the next course of action to be for this patient? 1. Adopt the "watch and wait" approach. 2. Reduce caffeine intake. 3. Apply warm soaks to the cyst. 4. Have a surgical biopsy. Answer: 4 Explanation: 1. Breast masses are not watched. 2. Reducing caffeine intake is suggested for women with fibrocystic breast disease; it is not the best course of action for this scenario. 3. Warm soaks are not applicable for this condition. 4. A percutaneous needle biopsy is used to define cystic mass or fibrocystic changes and provide specimens for cytologic examination, and a breast biopsy. In aspiration biopsy or fineneedle aspiration biopsy, a needle is used to remove cells or fluid from the breast lesion. Fine needle aspiration biopsies are performed using a stereotactic biopsy device with mammography and a computer to guide the needle. Page Ref: 1819 Cognitive Level: Analyzing Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 49.6 Describe the pathophysiology and manifestations of disorders of the breast, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

16 ..

17) A female patient is recovering from breast cancer surgery that included axillary node dissection. For which potential complication should the nurse plan teaching for this patient? 1. Lymphedema 2. Metastasis 3. Anemia and bleeding 4. Altered shoulder movement Answer: 1 Explanation: 1. Axillary node dissection is generally performed during surgery for all invasive breast carcinomas to stage the tumor. This surgery can cause lymphedema. 2. Removal of the lymph nodes does not increase the risk of metastasis. 3. Removal of the lymph nodes does not increase the risk of anemia or bleeding. 4. Range of motion exercises should be performed on the affected arm to help develop collateral lymph drainage. Page Ref: 1820 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Reduction of Risk Potential Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Planning/Teaching/Learning Learning Outcome: 49.6 Describe the pathophysiology and manifestations of disorders of the breast, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for women with reproductive system and breast disorders.

17 ..

18) During a routine patient admission history, a patient reports light bleeding between menstrual periods. What initial action by the nurse is most appropriate? 1. Determining the timing of the bleeding episodes 2. Determining the amount of bleeding 3. Assessing for the presence of sexually transmitted infections 4. Reviewing the length of the patient's normal menstrual cycles Answer: 1 Explanation: 1. Intermenstrual bleeding is characterized by bleeding in between normal menses and can be caused by hormonal imbalances or pelvic neoplasms. It is important to identify the timing of the bleeding to determine the underlying cause. 2. Assessment of the amount of bleeding is next in importance. 3. There is no indication the patient has a sexually transmitted infection. 4. The length of the menstrual cycle is part of the data collected but is not of the greatest importance. Page Ref: 1795 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Techniques of Physical Assessment Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Context and Environment; Knowledge; transcultural approaches to health | Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 1. Examine the pathophysiology, incidence, risk factors, and clinical manifestations for women with reproductive system and breast disorders.

18 ..

19) A 25-year-old patient has been experiencing abnormal uterine bleeding and is concerned about maintaining fertility. About which therapy should the nurse instruct this patient? Select all that apply. 1. Oral contraceptives 2. Progestin therapy 3. Therapeutic D&C 4. Endometrial ablation 5. Iron replacement therapy Answer: 1, 2, 5 Explanation: 1. Hormonal therapy or a hormonal releasing intrauterine device may be used. 2. Hormonal therapy or a hormonal releasing intrauterine device may be used. 3. Therapeutic D&C would not be indicated for this health problem. 4. Endometrial ablation would destroy the patient's fertility. 5. Oral iron supplements may be prescribed to replace iron lost through menstrual bleeding. Page Ref: 1796 Cognitive Level: Applying Client Need & Sub: Physiological Integrity: Pharmacological and Parenteral Therapies Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Context and Environment; Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 2. Consider intraprofessional care for women with reproductive system and breast disorders.

19 ..

20) A patient has been experiencing the clinical manifestations associated with menopause and expresses an interest in using alternative and complementary therapies to manage them. What is the best response by the nurse? 1. "Alternative and complementary therapies seldom work." 2. "Many women report success with those measures." 3. "What types of therapies are of interest to you?" 4. "Have you discussed this with the healthcare provider?" Answer: 3 Explanation: 1. The success of these remedies varies by user. It is inappropriate for the nurse to meet the patient's request with negativity. 2. This would not be the initial response in this scenario. 3. Alternative and complementary therapies are used by many women to manage the manifestations associated with menopause. The nurse has a responsibility to collect data from the patient. The nurse will need to determine which types of therapies are of interest to the patient. 4. This would not be the initial response in this scenario. Patients using alternative therapies are asked to report them to their healthcare providers. Page Ref: 1799 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Self-Care Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Assessment/Communication and Documentation Learning Outcome: 49.3 Describe the pathophysiology and manifestations of perimenopause, and outline the interprofessional care and nursing care of patients with this condition. MNL Learning Outcome: 3. Analyze assessment data to determine a plan of care for women with reproductive system and breast disorders.

20 ..

21) A 30-year-old patient reports increased irritability during the days preceding the onset of her menstrual cycle. What should the nurse suggest to assist in the management of her irritability? Select all that apply. 1. Increasing dietary sugar intake to promote energy 2. Increasing intake of simple carbohydrates 3. Reducing caffeine intake 4. Using guided imagery 5. Drinking two glasses of red wine each evening Answer: 3, 4 Explanation: 1. Dietary intake can be modified to aid in the management of premenstrual syndrome. Sugar intake should be reduced. 2. Dietary intake can be modified to aid in the management of premenstrual syndrome. The intake of simple carbohydrates should be reduced. 3. A reduction in caffeine intake is indicated to reduce irritability. 4. Guided imagery can be used to reduce stress and promote relaxation. 5. Alcohol intake should be limited. Page Ref: 1791 Cognitive Level: Applying Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for women with reproductive system and breast disorders.

21 ..

22) A patient who has been experiencing premenstrual syndrome (PMS) reports to the clinic with a diet diary she has kept over the past several weeks. For which entry should the nurse recommend making a dietary change? 1. Daily intake of caffeine-free soda 2. Daily intake of low-fat yogurt 3. Daily intake of foods rich in magnesium 4. Daily intake of white bread Answer: 4 Explanation: 1. Reducing caffeine is beneficial in the management of premenstrual syndrome. 2. Increasing calcium is beneficial in the management of premenstrual syndrome. 3. Increasing magnesium is beneficial in the management of premenstrual syndrome. 4. Simple carbohydrates should be reduced. White bread should be traded for whole-grain bread if possible. Page Ref: 1791 Cognitive Level: Analyzing Client Need & Sub: Health Promotion and Maintenance: Health Promotion/Disease Prevention Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient-centered care | AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care | NLN Competencies: Relationship-Centered Care; Practice-Know-How; Communicate information effectively | Nursing/Integrated Concepts: Nursing Process: Implementation/Teaching/Learning Learning Outcome: 49.2 Describe the pathophysiology and manifestations of menstrual disorders, and outline the interprofessional care and nursing care of patients with these disorders. MNL Learning Outcome: 4. Determine appropriate nursing interventions for women with reproductive system and breast disorders.

22 ..