LeMone/Burke/Bauldoff/ Gubrud, Medical-Surgical Nursing 6th Edition Test Bank. (All Chapters Covered)
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 1 Question 1 Type: MCSA The nurse is instructing a patient 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 Correct Answer: 3 Rationale 1: Identifying safety hazards and measuring quality is an example of the core competency quality improvement. Rationale 2: Using best research when providing patient care is an example of the core competency evidencebased practice. Rationale 3: The nurse instructing the patient is an example of the competency patient-centered care. Rationale 4: The core competency teamwork and collaboration involves collaboration between disciplines to provide continuous and reliable care. Global Rationale: In 2003, the National Academy of Sciences proposed a set of five core competencies that all healthcare professionals should possess to meet the needs of the 21st century. The nurse instructing the patient is an example of the competency patient-centered care. Identifying safety hazards and measuring quality are examples of the core competency quality improvement. Using best research when providing patient care is an example of the core competency evidence-based practice. Collaboration between disciplines to provide continuous and reliable care is an example of the core competency teamwork and collaboration. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essential Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage,
age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care: Learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 10.5.4. Utilize the nursing process in care of client. Page Number: 4 Question 2 Type: MCSA 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. Correct Answer: 4 Rationale 1: Changing the sharps container is an example of quality improvement. Rationale 2: Documenting the effectiveness of pain medication for a patient is an example of patient-centered care. Rationale 3: Discussing the effectiveness of bedside physical therapy with the therapist is an example of teamwork and collaboration. Rationale 4: Searching through a database of articles to find current research on wound care is an example of use informatics. Global Rationale: Examples of the nurse using the core competency use informatics include the use of technology to communicate, manage knowledge, reduce errors, and support decision making. The activity of searching through a database of articles to find current research on wound care is an example of use informatics. Changing the sharps container in a patient’s room is an example of quality improvement. Documenting the effectiveness of pain medication for a patient is an example of patient-centered care. Discussing the effectiveness of bedside physical therapy with the therapist is an example of teamwork and collaboration. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Electronic databases; literature retrieval; evaluating data for validity and reliability; evidence and best practices for nursing Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 4.3.3. Examine the treatments used for pressure ulcers. Page Number: 4 Question 3 Type: MCMA The nurse plans to implement evidence-based practice when providing patient care. Which activities should the nurse perform? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: Participating in education and research activities when possible is an example of implementing evidence-based practice in the provision of patient care. Rationale 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. Rationale 3: Serving on the committee to create critical pathways for patient care is an example of teamwork and collaboration. Rationale 4: Reinforcing hand hygiene techniques with unlicensed assistive personnel is an example of quality improvement. Rationale 5: Contacting Environmental Services to report a malfunctioning infusion pump is an example of quality improvement. Global Rationale: Participating in education and research activities when possible is an example of implementing evidence-based practice in the provision of patient care. Integrating research findings with clinical care to maximize patient outcomes is an example of implementing evidence-based practice in the provision of patient
care. Serving on the committee to create critical pathways for patient care is an example of teamwork and collaboration. Reinforcing hand hygiene techniques with unlicensed assistive personnel is an example of quality improvement. Contacting Environmental Services to report a malfunctioning infusion pump is an example of quality improvement. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: Page Number: 4 Question 4 Type: MCSA The community health 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 physician to see patients. 3. Attend a continuing education program on clean water initiatives. 4. Evaluate the effectiveness of weight reduction strategies. Correct Answer: 1 Rationale 1: Providing smoking cessation classes and literature is an example of an activity to provide patientcentered care. Rationale 2: Increasing the hours for the physician to see patients is an activity to support the competency teamwork and collaboration. Rationale 3: Attending a continuing education program on clean water initiatives is an activity to support the competency evidence-based practice. Rationale 4: Evaluating the effectiveness of weight reduction strategies is an activity to support the competency quality improvement.
Global Rationale: Activities to exemplify the core competency patient-centered care should be focused on disease prevention, wellness, and promotion of healthy lifestyles. Providing smoking cessation classes and literature is an example of patient-centered care. Increasing the hours for the physician to see patients is an activity to support the competency teamwork and collaboration. Attending a continuing education program on clean water initiatives is an activity to support the competency evidence-based practice. Evaluating the effectiveness of weight reduction strategies is an activity to support the competency quality improvement. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; health promotion/disease prevention Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: 5.9.4. Utilize the nursing process in care of client. Page Number: 4 Question 5 Type: MCSA 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 Correct Answer: 1 Rationale 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.
Rationale 2: The American Nurses Association Standards of Professional Practice are standards, not a code, and focus on specific behaviors to address quality practice, practice evaluation, education, collegiality, collaboration, ethics, research, resource utilization, and leadership. Rationale 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. Rationale 4: The state boards of nursing do not publish codes for nursing. Global Rationale: 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. The American Nurses Association Standards of Professional Practice are standards, not a code, and focus on specific behaviors to address quality practice, practice evaluation, education, collegiality, collaboration, ethics, research, resource utilization, and leadership. 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. The state boards of nursing do not publish codes for nursing. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; health promotion/disease prevention Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: 5.9.4. Utilize the nursing process in care of client. Page Number: 9 Question 6 Type: MCSA 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
Correct Answer: 1 Rationale 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, evidencebased practice and research, quality nursing practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. Rationale 2: Implementing a patient’s plan of care is an example of adhering to the American Nurses Association Standards of Practice. Rationale 3: Evaluating patient progress toward identified outcomes is an example of adhering to the American Nurses Association Standards of Practice. Rationale 4: Analyzing assessment data to determine issues is an example of adhering to the American Nurses Association Standards of Practice. Global Rationale: The nurse who is practicing within the American Nurses Association Standards of Professional Performance would integrate research findings into practice. The standards focus ethics, education, evidence-based practice and research, quality nursing practice, communication, leadership, collaboration, professional practice evaluation, resource utilization, and environmental health. The other activities would be implemented when the nurse is adhering to the American Nurses Association Standards of Practice. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: Page Number: 10 Question 7 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Assessment activities include data collection. Rationale 3: Diagnosis activities include analyzing data to determine issues. Rationale 4: Implementation activities include implementing the identified plan, coordinating care delivery, and employing strategies to promote health and a safe environment. Global Rationale: 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. Assessment activities include data collection. Diagnosis activities include analyzing data to determine issues. Implementation activities include implementing the identified plan, coordinating care delivery, and employing strategies to promote health and a safe environment. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: Page Number: 10 Question 8 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Modified activities of daily living may not affect pain control. Rationale 3: Enforcement of strict bed rest may not affect pain control. Rationale 4: Dietary interventions to maximize strength may not affect pain control. Global Rationale: 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. Modified activities of daily living, enforcement of strict bed rest, and dietary interventions to maximize strength may not affect pain control. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: 3.4.3. Critique interventions appropriate for the client with cancer. Page Number: 9 Question 9 Type: MCSA A patient is angry after waiting over an hour for pain medication. What should the nurse respond to the patient that demonstrates critical thinking? 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.” Correct Answer: 1 Rationale 1: Critical thinking is evident when the nurse challenges assumptions, overtly identifies and acknowledges the values and beliefs he/she brings to the situation, considers the influence of context, generates possible explanations, and deliberately maintains healthy skepticism. For the patient who is angry, this statement demonstrates empathy and critical thinking. Rationale 2: This statement is not an example of critical thinking and would be an inappropriate response. Rationale 3: This statement is not an example of critical thinking and would be an inappropriate response. Rationale 4: This statement is not an example of critical thinking and would be an inappropriate response. Global Rationale: Critical thinking is evident when the nurse challenges assumptions, overtly identifies and acknowledges the values and beliefs he/she brings to the situation, considers the influence of context, generates possible explanations, and deliberately maintains healthy skepticism. As the patient is angry, the statement that demonstrates empathy and critical thinking is “I understand your anger and am sorry for the delay. I have your pain medication now.” The other choices are not examples of critical thinking and would be inappropriate responses. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 4 Question 10 Type: MCSA The nurse is reviewing data collected from a patient during an assessment. Which activity demonstrates that the nurse is using divergent thinking when analyzing this data? 1. The nurse identifies abnormal data for further analyzing. 2. The nurse focuses on normal data to rule out health problems.
3. The nurse discriminates between facts and guesses. 4. The nurse thinks about the information to determine solutions. Correct Answer: 1 Rationale 1: Divergent thinking, a critical-thinking skill, is the ability to weigh the importance of information. The nurse should sort out the data that are relevant from data that are irrelevant for the patient, remembering that abnormal data are usually considered relevant. Rationale 2: Normal data are helpful but may not change the care to provide to the patient. This is not divergent thinking because it does not weigh the importance of the information. Rationale 3: Discriminating between facts and guesses describes the critical-thinking skill of reasoning. Rationale 4: Thinking about the information to determine solutions describes the critical-thinking skill of reflection. Global Rationale: Divergent thinking, a critical-thinking skill, is the ability to weigh the importance of information. The nurse should sort out the data that are relevant from data that are irrelevant for the patient. Abnormal data are usually considered relevant; normal data are helpful but may not change the care to provide to the patient. Discriminating between facts and guesses describes the critical-thinking skill of reasoning. Thinking about the information to determine solutions describes the critical-thinking skill of reflection. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 4 Question 11 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. Identified outcome criteria 4. Established priorities Correct Answer: 1 Rationale 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. Rationale 2: Communication techniques would be needed when conducting the patient assessment. Rationale 3: Identification of outcome criteria is a part of the planning phase of the nursing process. Rationale 4: Priorities are established during the implementation phase of the nursing process. Global Rationale: 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. Communication techniques would be needed when conducting the patient assessment. Identification of outcome criteria is a part of the planning phase of the nursing process. Priorities are established during the implementation phase of the nursing process. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 6 Question 12 Type: MCSA The nurse plans and implements care for a patient based on nursing knowledge and skills. In which role is the nurse functioning?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Caregiver 2. Advocate 3. Educator 4. Leader Correct Answer: 1 Rationale 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. Rationale 2: The nurse functioning as a patient advocate actively promotes the patient’s rights to autonomy and free choice. Rationale 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. Rationale 4: The nurse functioning in the role of leader directs, delegates, and coordinates nursing activities. Global Rationale: 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. The nurse functioning as a patient advocate actively promotes the patient’s rights to autonomy and free choice. 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. The nurse functioning in the role of leader directs, delegates, and coordinates nursing activities. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care 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: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 11 Question 13 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not explain the procedure to the patient. This is not patient advocacy. Rationale 3: The nurse should not do anything beyond documenting the patient’s lack of understanding about the procedure. Rationale 4: The nurse should not provide alternatives to the surgical procedure. Global Rationale: 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. The nurse should not explain the procedure to the patient. The nurse should not do anything beyond documenting the patient’s lack of understanding about the procedure. The nurse should not provide alternatives to the surgical procedure. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.2. Communicate patient values, preferences and expressed needs to other members of health care team AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care 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: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 13 Question 14 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 1: The nurse is functioning as an educator by instructing the patient on annual tests to maintain health. Rationale 2: As a researcher, the nurse would have a goal to improve the care nurses provide to patients. Rationale 3: As an advocate, the nurse actively promotes the patient’s rights to autonomy and free choice. Rationale 4: As a leader, the nurse manages time, people, and resources by delegating, directing, and coordinating nursing activities. Global Rationale: The nurse is functioning as an educator by instructing the patient on annual tests to maintain health. As a researcher, the nurse would have a goal to improve the care nurses provide to patients. As an advocate, the nurse actively promotes the patient’s rights to autonomy and free choice. As a leader, the nurse manages time, people, and resources by delegating, directing, and coordinating nursing activities. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: 10.5.4. Utilize the nursing process in care of client. Page Number: 12 Question 15 Type: MCMA The nurse is providing care within the primary nursing delivery model. Which leadership activities should the nurse perform within this model? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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. Correct Answer: 1, 5 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 5: When providing care to patients within the primary nursing care delivery model, leadership activities of the nurse include creating discharge plans. Global Rationale: 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, and planning the discharge of the patients. 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 provider. In the transitional care coordination model, leadership activities of the nurse include making referrals, managing the quality of care to include timeliness and cost, managing a caseload of patients, and managing the health team members providing care to the patients. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 13 Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Critical pathways are used primarily to manage disease conditions. Rationale 3: Evidence-based practice is used primarily to manage disease conditions. Rationale 4: Variance analyzing implies the use of statistics-based research. Global Rationale: 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. Critical pathways and evidence-based practice are used primarily to manage disease conditions. Variance analyzing implies the use of statistics-based research. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 5 Question 17 Type: MCSA The nurse stops to think about a previous patient care situation before providing care to a current patient. What type of thinking is this nurse performing? 1. Reflective 2. Divergent 3. Systematic 4. Creative Correct Answer: 1 Rationale 1: Reflective thinking involves two kinds of thinking. Reflecting-in-action occurs while a situation is being addressed. Reflecting-on-action is deliberate, occurs after an event, and creates embodied knowledge and skillfulness that will influence what the nurse perceives as salient when confronted with similar patient situations in the future. Rationale 2: Divergent thinking is the ability to weigh the importance of information. Rationale 3: Systematic thinking involves collecting, analyzing, and organizing information in a methodical manner that supports development of pattern recognition. Rationale 4: Creative thinking involves clinical imagination that integrates science, skilled know-how, and practical knowledge to develop unique solutions to individual patient needs. Global Rationale: Reflective thinking involves two kinds of thinking. Reflecting-in-action occurs while a situation is being addressed. Reflecting-on-action is deliberate, occurs after an event, and creates embodied knowledge and skillfulness that will influence what the nurse perceives as salient when confronted with similar patient situations in the future. Divergent thinking is the ability to weigh the importance of information. Systematic thinking involves collecting, analyzing, and organizing information in a methodical manner that supports development of pattern recognition. Creative thinking involves clinical imagination that integrates science, skilled know-how, and practical knowledge to develop unique solutions to individual patient needs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 4 Question 18 Type: MCSA A 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 Correct Answer: 1 Rationale 1: The nursing process can serve as a framework for the evaluation of quality care. Rationale 2: The use of critical pathways would not provide the best, recommended means to evaluate a patient care process. Rationale 3: The use of variance analysis would not provide the best, recommended means to evaluate a patient care process. Rationale 4: The use of evidence-based practice would not provide the best, recommended means to evaluate a patient care process. Global Rationale: The nursing process can serve as a framework for the evaluation of quality care. The use of critical pathways, variance analysis, and evidence-based practice would not provide the best, recommended means to evaluate a patient care process. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 5 Question 19 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: During the assessment phase, the nurse is actively collecting data. Rationale 3: Implementation is the phase of the nursing process during which the nurse performs interventions. Rationale 4: Determining the needs of the patient and devising a plan of action take place during the planning phase. Global Rationale: 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. During the assessment phase, the nurse is actively collecting data. Implementation is the phase of the nursing process during which the nurse performs interventions. Determining the needs of the patient and devising a plan of action take place during the planning phase. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.C.10. Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 9 Question 20 Type: MCSA 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 Correct Answer: 1 Rationale 1: Information that is perceived only by the person experiencing it is subjective data. Rationale 2: Evaluative data is used to assess responses to care. Rationale 3: Qualitative data refers to the presence or absence of a factor. Rationale 4: Objective data can be measured by someone or something other than the patient. Global Rationale: Information that is perceived only by the person experiencing it is subjective data. Evaluative data is used to assess responses to care. Qualitative data refers to the presence or absence of a factor. Objective data can be measured by someone or something other than the patient. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 6 Question 21 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The initial assessment refers to the first interaction. Rationale 3: Subjective assessment is not indicated in this scenario. Rationale 4: Objective assessment is not indicated in this scenario. Global Rationale: 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. The initial assessment refers to the first interaction. Subjective and objective assessments are not indicated in this scenario. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 6 Question 22 Type: MCSA 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 Correct Answer: 1 Rationale 1: Diagnostic reasoning is a form of clinical judgment used to make decisions about which diagnostic label best describes the patterns of patient data. Rationale 2: Evidence-based practice refers to the implementation of care initiatives that have been supported by research. Rationale 3: A critical pathway is a health care plan developed to provide care with a multidisciplinary, managed action focus. Rationale 4: The nursing process is a series of critical thinking and clinical reasoning activities nurses use as they provide care to patients. Global Rationale: Diagnostic reasoning is a form of clinical judgment used to make decisions about which diagnostic label best describes the patterns of patient data. Evidence-based practice refers to the implementation of care initiatives that have been supported by research. A critical pathway is a healthcare plan developed to provide care with a multidisciplinary, managed action focus. The nursing process is a series of critical thinking and clinical reasoning activities nurses use as they provide care to patients. Cognitive Level: Applying Client Need: Safe and Effective Care Environment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Management of Care 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 6 Question 23 Type: MCSA 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 Correct Answer: 1 Rationale 1: Outcome criteria for nursing diagnoses are patient-centered, time-specific, and measurable. They are classified into three domains: cognitive, affective, and psychomotor. Rationale 2: The focus of the outcome criteria is the patient, not the nurse. Rationale 3: While the outcome criteria are often written as statements, this option does not encompass all of the criteria that are to be included. Rationale 4: Outcome criteria are not limited to psychomotor skills; they may also be cognitive or affective. Global Rationale: Outcome criteria for nursing diagnoses are patient-centered, time-specific, and measurable. They are classified into three domains: cognitive, affective, and psychomotor. The focus of the outcome criteria is the patient, not the nurse. While the outcome criteria are often written as statements, this option does not encompass all of the criteria that are to be included. Outcome criteria are not limited to psychomotor skills; they may also be cognitive or affective. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Contribute to assessment of outcome achievement Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 7
Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 1: Documenting interventions is the final component of implementation as well as a legal requirement. Rationale 2: Ongoing assessment of the patient is an essential component of implementation, but it is not the final step. Rationale 3: Measuring vital signs can be completed at any time and not necessarily at the end of implementing the plan of care. Rationale 4: Providing report is an ongoing process and is not necessarily completed after implementing the plan of care. Global Rationale: Documenting interventions is the final component of implementation as well as a legal requirement. Ongoing assessment of the patient is an essential component of implementation, but it is not the final step. Measuring vital signs can be completed at any time and not necessarily at the end of implementing the plan of care. Providing report is an ongoing process and is not necessarily completed after implementing the plan of care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 9 Question 25 Type: MCSA 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. The unit’s nurse manager is concerned that care was not appropriately provided. What should be consulted to protect the patient and to evaluate the care in question? 1. Nursing Code of Ethics 2. Hospital quality improvement guidelines 3. Nurse Practice Act 4. Critical pathway Correct Answer: 1 Rationale 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. Rationale 2: Quality improvement uses data to monitor the outcomes of care and the processes used to deliver that care. Rationale 3: The Nurse Practice Act provides the standards for an individual state’s stance on the nurse’s scope of practice. Rationale 4: A critical pathway is a healthcare plan developed to provide care with a multidisciplinary, managed action focus. Global Rationale: 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. Quality improvement uses data to monitor the outcomes of care and the processes used to deliver that care. The Nurse Practice Act provides the standards for an individual LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
state’s stance on the nurse’s scope of practice. A critical pathway is a healthcare plan developed to provide care with a multidisciplinary, managed action focus. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.7. Explore ethical and legal implications of patient-centered 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: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: Page Number: 9 Question 26 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Following written orders is considered a basic caregiver skill. Rationale 3: Using critical thinking would be considered a basic caregiver skill. Rationale 4: The ability to support patient decision making relates to the role of patient advocate. Global Rationale: 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. Following written orders and using critical thinking would be considered basic caregiver skills. The ability to support patient decision making relates to the role of patient advocate. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; learn cooperatively, facilitate the learning of others. Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 13 Question 27 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Functional nursing is not a recognized term. Rationale 3: In primary nursing, total nursing care is provided by the assigned nurse. Rationale 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. Global Rationale: 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. Functional nursing is not a recognized term. In primary nursing, total nursing care is provided by the assigned nurse. 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Relationship Centered Care; Knowledge; Team building and team dynamics Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 13 Question 28 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: The nurse retains responsibility/accountability for the vital signs. Rationale 3: The nurse is accountable for reviewing the data collected and ensuring it is done appropriately. Rationale 4: The purpose of delegation is to share tasks appropriately, not to increase the workload of the primary nurse. Global Rationale: 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. The nurse retains responsibility/accountability for the vital signs. The nurse is accountable for reviewing the data collected and ensuring it is done appropriately. The purpose of delegation is to share tasks appropriately, not to increase the workload of the primary nurse. Cognitive Level: Applying Client Need: Safe and Effective Care Environment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Management of Care 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: Relationship Centered Care; Knowledge; Team building and team dynamics Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 14 Question 29 Type: MCSA Quality assurance chart audits provide nurses with information that impacts the future outcomes of patient care. What should the nurses 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. Correct Answer: 1 Rationale 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 are expected to use the information if it will have a positive impact on the nursing practice. Rationale 2: There is no real purpose to sharing the results of a quality assurance audit with the hospital administrator. Rationale 3: While the accrediting body of an institution may encourage quality improvement activities, there is no reason to provide the chart audit results. Rationale 4: Nurses are expected to use the information if it will have a positive impact on the nursing practice. Global Rationale: The results of quality assurance audits can be used to develop a plan of action to resolve differences or issues with patient care. There is no real purpose to sharing the results of a quality assurance audit with the hospital administrator. While the accrediting body of an institution may encourage quality improvement activities, there is no reason to provide the chart audit results. Nurses are expected to use the information if it will have a positive impact on the nursing practice. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV.B. 5. Use quality measures to understand performance 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; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: Page Number: 4 Question 30 Type: MCSA A graduate nurse attends a seminar regarding the role of the nurse as a patient advocate. Which statement by the 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.” Correct Answer: 1 Rationale 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. Rationale 2: This is an element of being a successful patient advocate. Rationale 3: This is an element of being a successful patient advocate. Rationale 4: This is an element of being a successful patient advocate. Global Rationale: 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. The remaining answer choices are elements of being a successful patient advocate. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.B.2. Communicate patient values, preferences and expressed needs to other members of health care team AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care NLN Competencies: Knowledge and Science; Practice; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 13 Question 31 Type: MCMA The nurse is assessing a patient with pain in the lower back. Which questions or results indicate the nurse is using divergent thinking during the assessment process? Standard Text: Select all that apply. 1. “Tell me about your dietary practices.” 2. “Can you tell me on a scale of 1 to 10, with 10 being the worst, how you would rate your pain now?” 3. The nurse notes a cluster of blisters on the patient’s scapula. 4. “When was the last time you had a physical?” 5. “Does your eyesight affect your ability to see the insulin you are taking?” Correct Answer: 2, 3, 5 Rationale 1: Normal data are helpful but may not change the care the nurse provides. Rationale 2: Divergent thinking is the ability to weigh the importance of information. When collecting data from a patient, the nurse can sort out the data that are relevant for care from the data that are not relevant. Rationale 3: Divergent thinking is the ability to weigh the importance of information. When collecting data from a patient, the nurse can sort out the data that are relevant for care from the data that are not relevant. Rationale 4: Normal data are helpful but may not change the care the nurse provides. Rationale 5: Divergent thinking is the ability to weigh the importance of information. When collecting data from a patient, the nurse can sort out the data that are relevant for care from the data that are not relevant.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Divergent thinking is the ability to weigh the importance of information. When collecting data from a patient, the nurse can sort out the data that are relevant for care from the data that are not relevant. Normal data are helpful but may not change the care the nurse provides. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Translate research into practice in order to promote quality and improve practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 4 Question 32 Type: SEQ Arrange in order the steps the nurse should take in a focused assessment for a patient with type 2 diabetes mellitus. Standard Text: Click and drag the options below to move them up or down. Choice 1. Nurse notes patient is reluctant to draw up insulin in syringe. Choice 2. Nurse assesses what the patient already knows. Choice 3. Nurse has patient practice drawing up insulin. Choice 4. Nurse calls in diabetic educator. Choice 5. Nurse notes patient is not aware of differences between hypo- and hyperglycemia. Correct Answer: 2, 5, 1, 3, 4 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Focused assessments are ongoing and continuous. Data are used to evaluate nursing actions and make decisions about whether to continue or change interventions to meet outcomes. Assessments also provide structure for documenting nursing care, enable responses to a disease process or treatment, and identify new problems. For this situation, the nurse should follow the nursing process and begin by assessing what the patient already knows. From this, the nurse would note that the patient does not know the difference between hypo- and hyperglycemia. The nurse would also observe that the patient is reluctant to draw up insulin and would address this reluctance by having the patient practice. Finally the nurse would consult with a diabetic educator to assist with the patient’s teaching. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: 10.5.4. Utilize the nursing process in care of client. Page Number: 6 Question 33 Type: MCSA The director of nursing is reviewing situations that require attention. Which situation is an ethical dilemma that might need to be studied 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 his 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. Correct Answer: 1 Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Rationale 2: This situation is not a dilemma but may violate standards of care or standards of practice. Rationale 3: This situation is not a dilemma but may violate standards of care or standards of practice. Rationale 4: This situation is not a dilemma but may violate standards of care, codes of ethics, or standards of practice. Global Rationale: 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. The other situations are not dilemmas but may violate standards of care, codes of ethics, or standards of practice. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.7. Explore ethical and legal implications of patient-centered 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: Diagnosis Learning Outcome: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: Page Number: 11 Question 34 Type: MCMA The nurse is approached by a patient who offers to provide the nurse with tickets to a sporting event in exchange for free home care for 1 week. The nurse accepts this offer. Which standards did the nurse violate? Standard Text: Select all that apply. 1. HIPAA 2. ANA standards 3. Professional boundaries LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. State nurse practice acts 5. Standards pertinent to specific hospital protocols Correct Answer: 3, 4 Rationale 1: HIPAA involves violations of patient confidentiality. Rationale 2: A violation of ethics in the ANA Standards of Care would not apply here. Rationale 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. Rationale 4: Professional boundaries are outlined in individual state nurse practice acts. Rationale 5: Hospital protocols are not identified in the question; however, the nurse’s action violates a professional boundary. Global Rationale: 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. HIPAA addresses confidentiality. ANA standards address ethics and codes of conduct. Hospital protocols are not a part of this question. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.7. Explore ethical and legal implications of patient-centered 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: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: Page Number: 11 Question 35 Type: MCSA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. ICN Code of Ethics 2. ANA Standards of Practice 3. ANA Code of Ethics 4. State practice acts Correct Answer: 2 Rationale 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. Rationale 2: The nurse is violating the standards of leadership and collaboration by refusing to assist the students during the learning process. Rationale 3: The nurse is not violating the Code of Ethics. Rationale 4: The nurse is not violating the state nurse practice act. Global Rationale: The nurse is violating the standards of leadership and collaboration when refusing to assist the students during the learning process. The nurse is not violating a Code of Ethics or the state nurse practice act. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: 4. Explain the importance of nursing and interprofessional codes of ethics and standards of practice as guidelines for clinical nursing practice. MNL Learning Outcome: Page Number: 10 Question 36 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. Delegate 4. Advocate Correct Answer: 4 Rationale 1: The caregiver works independently and collaboratively with the patient. Rationale 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. Rationale 3: Delegates are nurses who are responsible for completing care as assigned. Rationale 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. Global Rationale: 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. The caregiver works independently and collaboratively with the patient. 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. Delegates are nurses who are responsible for completing care as assigned. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.2. Communicate patient values, preferences and expressed needs to other members of health care team AACN Essentials Competencies: VI.2. Use inter- and intraprofessional communication and collaborative skills to deliver evidence-based, patient-centered care 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: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 13 Question 37 Type: MCMA The director of nursing is meeting with the hospital administrator to plan an initiative to improve the quality and safety of patient care. After reviewing the Triple Aim approach, which actions should the director recommend? Standard Text: Select all that apply. 1. Improve the patient care experience. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Improve the health of populations. 3. Reduce the per capita costs of health care. 4. Implement evidence-based practice. 5. Support nursing continuing education plans. Correct Answer: 1, 2, 3 Rationale 1: The Triple Aim initiative was launched by The Institute of Health Improvement, which identified approaches to improve models for healthcare. Improving the patient care experience is one of the three critical objectives identified. Rationale 2: The Triple Aim initiative was launched by The Institute of Health Improvement, which identified approaches to improve models for healthcare. Improving the health of populations is one of the three critical objectives identified. Rationale 3: The Triple Aim initiative was launched by The Institute of Health Improvement, which identified approaches to improve models for healthcare. Reducing the per capita costs of health care is one of the three critical objectives identified. Rationale 4: Implementing evidence-based practice is not an objective identified by the Triple Aim. Rationale 5: Supporting nursing continuing education plans is not an objective identified by the Triple Aim. Global Rationale: The Triple Aim initiative was launched by The Institute of Health Improvement, which identified approaches to improve models for healthcare. This initiative identified three critical objectives: improve the patient care experience, improve the health of populations, and reduce the per capita costs of health care. Implementing evidence-based practice and supporting nursing continuing education plans are not objectives identified by the Triple Aim. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: IV.B.5. Use quality measures to understand performance AACN Essentials Competencies: II.11. Employ principles of quality improvement, healthcare policy, and costeffectiveness 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; Factors that contribute to a systemwide safety culture; the importance of reporting hazards and adverse events; the "just culture" approach to system improvement Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1.Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 3 Question 38 Type: MCSA 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? Correct Answer: 4 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. Research that does not improve patient care is not appropriate. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Explain the activities and characteristics of the nurse as caregiver, educator, advocate, leader and manager, and researcher. MNL Learning Outcome: Page Number: 14 Question 39 Type: SEQ The nurse is identifying nursing diagnoses for a patient’s care. In which order should the nurse complete this process? Standard Text: Click and drag the options below to move them up or down. 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. Identify significant cues. Correct Answer: 5, 3, 1, 2, 4 Rationale 1: Rationale 2: Rationale 3: Rationale 4: Rationale 5: Global Rationale: When identifying nursing diagnoses, the nurse should interpret the data, identify significant cues, cluster cues and identify data gaps, draw conclusions about the present health status, determine etiologies and categorize problems, and verify the problem or diagnoses. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Translate research into practice in order to promote quality and improve practices LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 6 Question 40 Type: MCMA 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? Standard Text: Select all that apply. 1. Health promotion 2. Disease prevention 3. Chronic disease management 4. Rehabilitation 5. Palliative care Correct Answer: 1, 2, 3 Rationale 1: The ACA will provide access to health care services for more Americans and create new models of care. The profession is well positioned to respond to new demands that emphasize health promotion. Rationale 2: The ACA will provide access to health care services for more Americans and create new models of care. The profession is well positioned to respond to new demands that emphasize disease prevention. Rationale 3: The ACA will provide access to health care services for more Americans and create new models of care. The profession is well positioned to respond to new demands that emphasize management of chronic disease. Rationale 4: Rehabilitation is not a new model of care that will be provided in a community health clinic. Rationale 5: Palliative care is not a new model of care that will be provided in a community health clinic. Global Rationale: The ACA will provide access to health care services for more Americans and create new models of care. The profession is well positioned to respond to new demands that emphasize health promotion, disease prevention, and management of chronic disease. Rehabilitation and palliative care are not new models of care that will be provided through a community health clinic. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Health Promotion and Maintenance Client Need Sub: 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. Describe emerging new roles and responsibilities for nurses in an era of healthcare reform. MNL Learning Outcome: Page Number: 2 Question 41 Type: MCMA The nurse manager is evaluating the use of evidence-based practice guidelines to guide care on a patient care area. Which observations indicate that these guidelines are being used appropriately? Standard Text: 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. Correct Answer: 2, 3, 4, 5 Rationale 1: Evidence-based practice guidelines are collections of practical information used to help guide decisions related to specific circumstances. These guidelines help identify appropriate interventions for a given nursing care problem or diagnosis. Posting the guidelines on the staff bulletin board does not indicate that they are being used appropriately. Rationale 2: Evidence-based practice guidelines are collections of practical information used to help guide decisions related to specific circumstances. These guidelines help identify appropriate interventions for a given nursing care problem or diagnosis. Basing patient care on a guideline indicates that it is being used appropriately. Rationale 3: Evidence-based practice guidelines are collections of practical information used to help guide decisions related to specific circumstances. These guidelines help identify appropriate interventions for a given nursing care problem or diagnosis. Placing a copy of the guideline in the Kardex to support a particular nursing diagnosis indicates that it is being used appropriately. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Evidence-based practice guidelines are collections of practical information used to help guide decisions related to specific circumstances. These guidelines help identify appropriate interventions for a given nursing care problem or diagnosis. Evidence-based nursing guidelines are available through specialty nursing organizations, healthcare systems, on the web, and in published resources. Observing staff access guidelines through the clinical documentation system indicates they are being used appropriately. Rationale 5: Evidence-based practice guidelines are collections of practical information used to help guide decisions related to specific circumstances. These guidelines help identify appropriate interventions for a given nursing care problem or diagnosis. Referring to a guideline before planning skin care interventions indicates the guideline is being used appropriately. Global Rationale: Evidence-based practice guidelines are collections of practical information used to help guide decisions related to specific circumstances. These guidelines help identify appropriate interventions for a given nursing care problem or diagnosis. Quoting a guideline in a nurse’s note, placing a copy of a guideline in a Kardex, accessing guidelines through the clinical documentation system, and referencing a guideline before planning skin care interventions indicate appropriate use of the guidelines. Posting a guideline on a bulletin board is not an appropriate use of a guideline. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the core competencies for healthcare professionals: patient-centered care, interprofessional teams, evidence-based practice, quality improvement, safety, and health information technology. MNL Learning Outcome: Page Number: 8 Question 42 Type: MCMA 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 actions should the committee members include when creating this care bundle? Standard Text: Select all that apply. 1. Narrow the patient population in which the bundle will be applied. 2. Define the number and type of range-of-motion exercises to be performed. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. Identify three interventions proven to reduce the development of contractures. 4. Communicate when the bundle has been completed and ready to for implementation. 5. Emphasize that interventions are recommendations to reduce the incidence of contractures. Correct Answer: 1, 3, 4 Rationale 1: Care bundles are multidisciplinary standards that pull together a short list of interventions and treatments that are already recommended and are generally accepted in national guidelines. For a care bundle to be successful, it must be written for a defined patient population in one location. The development of a bundle to prevent contractures in patients with limb paralysis from neurological health problems is too broad and needs to be further defined or narrowed. Rationale 2: Bundle elements should be descriptive rather than prescriptive, to allow for customization and appropriate clinical judgment. The bundle should state that range-of-motion exercises are to be done but not identify the number and type of exercises. Rationale 3: The bundle should have three to five interventions with strong clinician agreements. The bundles integrate a short list of already recommended guidelines that are accepted nationally or through consensus by local clinicians. Rationale 4: The multidisciplinary team develops the bundle. Communication and teamwork are essential to successful implementation of a bundle. Rationale 5: Compliance with bundles is measured using all-or-nothing measurement, with a goal of 95% or greater. If any of the interventions are not documented, implementation of the bundle is considered incomplete and no partial credit is given. Global Rationale: Care bundles are multidisciplinary standards that pull together a short list of interventions and treatments that are already recommended and are generally accepted in national guidelines. For a care bundle to be successful, it must be written for a defined patient population in one location. The development of a bundle to prevent contractures in patients with limb paralysis from neurological health problems is too broad and needs tobe further defined or narrowed. Bundle elements should be descriptive rather than prescriptive, to allow for customization and appropriate clinical judgment. The bundle should state that range-of-motion exercises are to be done but not identify the number and type of exercises. The bundle should have three to five interventions with strong clinician agreements. The bundles integrate a short list of already recommended guidelines that are accepted nationally or through consensus by local clinicians. The multidisciplinary team develops the bundle. Communication and teamwork are essential to successful implementation of a bundle. Compliance with bundles is measured using all-or-nothing measurement, with a goal of 95% or greater. If any of the interventions are not documented, implementation of the bundle is considered incomplete and no partial credit is given. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; accreditation standards Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe emerging new roles and responsibilities for nurses in an era of healthcare reform. MNL Learning Outcome: 8.1.3. Distinguish the diagnosis and treatment of traumatic musculoskeletal injuries. Page Number: 8 Question 43 Type: MCMA The nurse is coordinating care for patients within a patient-centered medical home. Which actions should the nurse prepare to complete when functioning in this role? Standard Text: 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. Correct Answer: 1, 2, 3, 5 Rationale 1: The nurse functioning as a care coordinator within a patient-centered medical home will be in contact with the patients after discharge to ensure continuity of care and health maintenance. Rationale 2: The nurse functioning as a care coordinator within a patient-centered medical home will monitor the implementation of the patient’s plan of care. Rationale 3: The nurse functioning as a care coordinator within a patient-centered medical home manages the quality of care provided, including accuracy, timeliness, and cost. Rationale 4: The patient-centered medical home 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. Rationale 5: The nurse functioning as a care coordinator within a patient-centered medical home collaborates with the patient to implement the plan of care. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The nurse functioning as a care coordinator within a patient-centered medical home will be in contact with the patients after discharge to ensure continuity of care and health maintenance. The nurse will also monitor the implementation of the patient’s plan of care; manage the quality of care provided, including accuracy, timeliness, and cost; and collaborate with the patient to implement the plan of care. The patient-centered medical home 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. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 costeffectiveness 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: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Describe emerging new roles and responsibilities for nurses in an era of healthcare reform. MNL Learning Outcome: Page Number: 13–14 Question 44 Type: MCMA The nursing instructor is planning activities to help students learn clinical decision making. Which activities should the instructor include to help the students develop foundational knowledge? Standard Text: Select all that apply. 1. Time for students to complete a self-assessment tool 2. Access to evidence-based guidelines for assigned patients 3. Expectations for participation in postclinical conferences 4. Office hours and dates when care plans are due for grading 5. Copies of the state practice act and standards of practice Correct Answer: 1, 2, 5
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Foundational knowledge used in clinical reasoning includes knowing the profession, self, the case, the patient, and the person. Planning time for students to complete a self-assessment tool helps them know the self. Rationale 2: Foundational knowledge used in clinical reasoning includes knowing the profession, self, the case, the patient, and the person. Providing access to evidence-based guidelines helps the students know the case. Rationale 3: Foundational knowledge used in clinical reasoning includes knowing the profession, self, the case, the patient, and the person. Stating expectations for participation in postclinical conferences do not help develop foundational knowledge. Rationale 4: Foundational knowledge used in clinical reasoning includes knowing the profession, self, the case, the patient, and the person. Stating office hours and due dates for work does not help develop foundational knowledge. Rationale 5: Foundational knowledge used in clinical reasoning includes knowing the profession, self, the case, the patient, and the person. Providing copies of the state practice act and standards of practice helps students know the profession. Global Rationale: Foundational knowledge used in clinical reasoning includes knowing the profession, self, the case, the patient, and the person. Planning time for students to complete a self-assessment tool helps them know the self. Providing access to evidence-based guidelines helps students know the case. Providing copies of the state practice act and standards of practice helps students know the profession. Stating expectations for participation in postclinical conferences and stating office hours and due dates for work does not help develop foundational knowledge. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; decision making in uncertainty Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Apply the attitudes, mental habits, and skills necessary for clinical reasoning when using the nursing process in patient care. MNL Learning Outcome: Page Number: 4
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff, Medical-Surgical Nursing 6th Edition Test Bank Chapter 2 Question 1 Type: MCSA After purchasing a personal computer for use at home, the nurse enrolls in classes at the local community college to learn more about using the device. Which building block of informatics competencies is this nurse demonstrating? 1. Computer literacy 2. Information literacy 3. Relationship analysis 4. Computer integration Correct Answer: 1 Rationale 1: The building blocks of informatics competencies begin with computer literacy or becoming familiar with a personal computer. Rationale 2: Information literacy is the ability to locate, evaluate, and use appropriate information effectively. Rationale 3: The nurse who is highly skilled in information and management technology skills is able to see relationships among data. Rationale 4: The informatics specialist has additional knowledge and is able to integrate and applies information/computer science to nursing. Global Rationale: The building blocks of informatics competencies begin with computer literacy or becoming familiar with a personal computer. Information literacy is the ability to locate, evaluate, and use appropriate information effectively. The nurse who is highly skilled in information and management technology skills is able to see relationships among data. The informatics specialist has additional knowledge and is able to integrate and applies information/computer science to nursing. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.A. 1. Explain why information and technology skills are essential for safe patient care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice NLN Competencies: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify the role of nursing informatics in nursing care. MNL Learning Outcome: Page Number: 18 Question 2 Type: MCSA While participating in the electronic communication committee, the nurse makes a recommendation to alter one aspect of the system to support nursing documentation. Which informatics competency is this nurse practicing? 1. Implement policies relevant to best practice. 2. Analyze and interpret information as part of planning care. 3. Use informatics applications designed for nursing practice. 4. Demonstrate expertise as a content expert in system design. Correct Answer: 4 Rationale 1: Implementing policies relevant to best practice is a basic informatics competency for all nurses. Rationale 2: Analyzing and interpreting information as part of planning care is a basic informatics competency for all nurses. Rationale 3: Using informatics applications designed for nursing practice is a basic informatics competency for all nurses. Rationale 4: Making a recommendation to alter an aspect of the computer system demonstrates expertise as a content expert in system design. Global Rationale: Making a recommendation to alter an aspect of the computer system demonstrates expertise as a content expert in system design. Basic informatics competencies for all nurses include implementing policies relevant to best practice, analyzing and interpreting information as part of planning care, and using informatics applications designed for nursing practice. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.C. 4. Value nurses' involvement in design, selection, implementation, and evaluation of information technologies to support patient care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IV. 1. Demonstrate skills in using patient care technologies, information systems, and communication devices that support safe nursing practice NLN Competencies: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems; Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify the role of nursing informatics in nursing care. MNL Learning Outcome: Page Number: 18 Question 3 Type: MCMA The manager is evaluating a beginning nurse’s ability to use the computerized documentation system. Which observations indicate that the beginning nurse needs additional training on the computer? Standard Text: Select all that apply. 1. Documented care for one patient in 20 minutes 2. Input patient safety data on the appropriate screen 3. Stated laboratory results not available when they were entered 4 hours earlier 4. Retrieved a recent peer-reviewed article supporting an aspect of one patient’s care 5. Commented that a paper chart is the only legal and reliable form of documentation Correct Answer: 1, 3, 5 Rationale 1: An informatics competency for the beginning nurse is demonstrating basic computer literacy and the ability to use desktop applications and electronic communication. Spending 20 minutes to document care for one patient does not indicate basic use of computers. Rationale 2: Inputting patient safety data on the appropriate screen indicates performance of the informatics competency of supporting patient safety initiatives using information technology. Rationale 3: An informatics competency for the beginning nurse is demonstrating basic computer literacy and the ability to use desktop applications and electronic communication. Stating that laboratory results were not available when they were entered 4 hours earlier indicates the nurse did not know how to retrieve the results. Rationale 4: Retrieving an article to support an aspect of patient care indicates performance of the informatics competency of knowledge to support clinical and administrative processes to support evidence-based practice. Rationale 5: An informatics competency for the beginning nurse is demonstrating basic computer literacy and the ability to use desktop applications and electronic communication.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Commenting that a paper chart is the only legal and reliable form of communication indicates that the nurse is unable to recognize the role of informatics in nursing. Global Rationale: An informatics competency for the beginning nurse is: demonstrate basic computer literacy and the ability to use desktop applications and electronic communication. Spending 20 minutes to document one patient’s care, stating that previously entered laboratory values were unavailable, and believing that paper is the only legal form of documentation indicate that the nurse needs additional training on the computer. Inputting patient safety data and retrieving an article indicate that training has been effective. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems; Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Identify the role of nursing informatics in nursing care. MNL Learning Outcome: Page Number: 18
Question 4 Type: MCMA The staff development trainer is preparing a seminar for experienced nurses on the computerized clinical documentation system. What should the trainer include in this presentation? Standard Text: Select all that apply. 1. Strategies to locate information quickly 2. Tips on using the computers and software efficiently 3. Reasons the documentation system supports patient care 4. Approaches to identify relationships among data elements 5. Case studies to analyze data patterns to make clinical judgments Correct Answer: 4, 5 Rationale 1: Strategies to locate information quickly would be essential for a beginning nurse to learn.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Tips to use the computer and software efficiently would be essential for a beginning nurse to learn. Rationale 3: Reasons the documentation system supports patient care would be essential for a beginning nurse to learn. Rationale 4: An informatics competency for an experienced nurse is the ability to see relationships amount data elements. Rationale 5: An informatics competency for an experienced nurse is the ability to execute clinical judgments based on observed data patterns. Global Rationale: For experienced nurses the trainer should include information about identifying relationships among data elements and ways to analyze data patterns to make clinical judgments. These actions support the informatics competencies for experienced nurses. Strategies to locate information quickly, tips for using the computer, and reasons for using a computerized documentation system support the informatics competencies for a beginning nurse. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Identify the role of nursing informatics in nursing care. MNL Learning Outcome: Page Number: 18
Question 5 Type: MCSA A patient asks why the nurse is playing with an iPad in the midst of providing care. What should the nurse respond to this patient? 1. “I’m just typing in notes to remember what care I provided to you.” 2. “This is just a way for nurses to communicate instead of calling out to each other.” 3. “I just needed to check and make sure I did everything that you needed at this time.” 4. “This is a part of the computer system that is used to confidentially document your care.” Correct Answer: 4 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: The nurse is doing more than typing notes to remember what care was provided to the patient. Rationale 2: The computerized documentation system is not a communication device used between nurses. Rationale 3: The computer is used for more than determining if all needed care was provided. Rationale 4: When providing patient care the nurse should explain the computer, why and how it is used, and how the patient’s confidential information is protected. Global Rationale: When providing patient care the nurse should explain the computer, why and how it is used, and how the patient’s confidential information is protected. The nurse is doing more than typing notes to remember what care was provided to the patient. The computerized documentation system is not a communication device used between nurses. The computer is used for more than determining if all needed care was provided. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the role of information technology such as computers and related software in nursing care. MNL Learning Outcome: Page Number: 19
Question 6 Type: MCSA The computerized clinical documentation system installed in a healthcare organization has a feature that alerts staff to potential safety hazards. Which computer message should the nurse interpret as a safety warning when providing patient care? 1. Warning: Scan the bar code on the item before using for patient care 2. Warning: Click on automatic calculation before leaving the graphic sheet section 3. Warning: Leaving the computer unattended for 1 minute will result in data not being saved 4. Warning: Administering this medication exceeds the maximum safe amount of acetaminophen LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 4 Rationale 1: Scanning the bar code on an item before using for patient care will ensure that the patient is charged for the item. This is not a safety hazard. Rationale 2: Clicking on automatic calculation before leaving the graphic sheet section ensures the documentation is complete. This is not a safety hazard. Rationale 3: Leaving the computer unattended for 1 minute resulting in data being lost will cause the nurse to re-input the information. This is not a safety hazard. Rationale 4: Electronic medical records have been shown to reduce errors. The record can be programmed to alert clinicians about potential medication errors such as exceeding a safe dose of acetaminophen. Global Rationale: Electronic medical records have been shown to reduce errors. The record can be programmed to alert clinicians about potential medication errors such as exceeding a safe dose of acetaminophen. Scanning the bar code on an item before using for patient care will ensure that the patient is charged for the item. Clicking on automatic calculation before leaving the graphic sheet section ensures the documentation is complete. Leaving the computer unattended for 1 minute resulting in data being lost will cause the nurse to re-input the information. These are not safety hazards. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: Context and Environment; Knowledge; Functionality of clinical and financial systems (data entry, documentation, data retrieval); interoperability of systems; Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Describe the role of information technology such as computers and related software in nursing care. MNL Learning Outcome: Page Number: 19
Question 7 Type: MCSA While documenting care provided to a patient in the home, the nurse encounters a problem with the electronic medical record. Which action indicates that the nurse was able to troubleshoot and address the problem? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Followed the steps in the technical difficulties guide and completed documentation 2. Closed the electronic medical record and documented care in a traditional hard-copy note 3. Telephoned the information technology department and reported a problem with the system 4. Used the patient’s personal computer to access the electronic record to record documentation Correct Answer: 1 Rationale 1: When integrating electronic documentation into practice, the nurse must be able to navigate manuals and troubleshoot problems to reduce care delays and frustrations if technical problems arise. Using the technical difficulties guide to complete documentation indicates that the nurse was able to troubleshoot and address the problem. Rationale 2: Writing a traditional hard-copy note indicates that the nurse was not successfully able to troubleshoot and address the problem. Rationale 3: Calling the information technology department to report a problem with the system indicates that the nurse was not successful at troubleshooting and addressing the problem. Rationale 4: The patient’s personal computer should not be used for clinical document because of confidentiality. This action indicates that the nurse was not successful at troubleshooting and addressing the problem. Global Rationale: When integrating electronic documentation into practice, the nurse must be able to navigate and troubleshoot problems to reduce care delays and frustrations if technical problems arise. Using the technical difficulties guide and completed documentation indicates that the nurse was able to troubleshoot and address the problem. Writing a hard-copy note, calling the information technology department, and using the patient’s personal computer all indicate that the nurse was not able to troubleshoot and address the problem. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.B.4. Document and plan patient care in an electronic health record 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; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe the role of information technology such as computers and related software in nursing care. MNL Learning Outcome: Page Number: 19
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 8 Type: MCMA The nurse is a member of a committee charged with selecting a computerized clinical information system for an organization. Which features should the nurse recommend be included in this system to support patient care needs? Standard Text: Select all that apply. 1. Standards of care 2. Quality improvement tracking database 3. Conditions of participation for health plans 4. Patient care policies and procedure manual 5. Clinical competency information and schedule Correct Answer: 1, 2, 4, 5 Rationale 1: Although patient care is the most common use for information technology, other applications are useful in nursing practice such as storing and managing standards of care. Rationale 2: Although patient care is the most common use for information technology, other applications are useful in nursing practice such as having a quality improvement tracking database. Rationale 3: Conditions of participation for health plans would be applicable for the billing department and would not necessarily support patient care. Rationale 4: Although patient care is the most common use for information technology, other applications are useful in nursing practice such as storing and managing policies and procedures. Rationale 5: Although patient care is the most common use for information technology, other applications are useful in nursing practice such as storing, managing, and organizing annual clinical competency information. Global Rationale: Although patient care is the most common use for information technology, other applications are useful in nursing practice such as storing and managing standards of care, tracking quality improvement, coordinating policies and procedures, and maintaining clinical competency information. Conditions of participation for health plans would be applicable for the billing department and will not necessarily support patient care. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: VI.C.2. Value technologies that support clinical decision-making, error prevention, and care coordination LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IV.3. Apply safeguards and decision making support tools embedded in patient care technologies and information systems to support a safe practice environment for both patients and healthcare workers NLN Competencies: Knowledge and Science; Practice; Use Databases for practice, administrative, education, and/or research purposes; document via electronic health records; use software applications related to nursing practice Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe the role of information technology such as computers and related software in nursing care. MNL Learning Outcome: Page Number: 19
Question 9 Type: MCMA The manager is on a committee that is investigating the implementation of evidenced-based practice for the nursing staff. Which outcomes should the manager highlight as expected when this approach is implemented? Standard Text: Select all that apply. 1. Reduces costs 2. Promotes the best patient outcomes 3. Encourages healthcare worker retention 4. Reduces the cost of healthcare worker salaries 5. Reduces care variations between geographic locations Correct Answer: 1, 2, 3, 5 Rationale 1: The use of EBP in nursing can help to reduce costs. Rationale 2: The use of EBP in nursing can help to promote the best patient outcomes. Rationale 3: The use of EBP in nursing can help to reduce care variations due to geographic locations. Rationale 4: The use of EBP in nursing is not used to reduce the cost of healthcare worker salaries. Rationale 5: The use of EBP in nursing can help to encourage healthcare worker retention. Global Rationale: The use of EBP in nursing can help to reduce costs, promote the best patient care outcomes, reduce care variations due to geographic locations, and encourage healthcare worker retention. The use of EBP is not used to reduce the cost of healthcare worker salaries. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice AACN Essentials Competencies: III.1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Define evidence-based practice (EBP) MNL Learning Outcome: Page Number: 20
Question 10 Type: MCMA The nurse is implementing evidence-based practice when caring for a patient with a chronic illness. Which actions indicate that the nurse is implementing this approach appropriately? Standard Text: Select all that apply. 1. Studies healthcare provider’s written orders 2. Analyzes patient’s requests for care approaches 3. Asks colleagues to identify best approaches to care 4. Plans intervention based upon researched information 5. Reviews findings from patient assessment and laboratory data Correct Answer: 2, 4, 5 Rationale 1: The healthcare provider’s written orders are not a step within the evidence-based practice process. Rationale 2: Evidence-based practice (EBP) is defined as the practice of nursing in which the nurse makes clinical decisions on the basis of the best available current research evidence; clinical expertise, including internal evidence of patient findings; and the needs and preferences of the patient. Rationale 3: Asking colleagues to identify best care approaches is not a step within the evidence-based practice process. Rationale 4: Evidence-based practice (EBP) is defined as the practice of nursing in which the nurse makes clinical decisions on the basis of the best available current research evidence; clinical expertise, including internal evidence of patient findings; and the needs and preferences of the patient. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Evidence-based practice (EBP) is defined as the practice of nursing in which the nurse makes clinical decisions on the basis of the best available current research evidence; clinical expertise, including internal evidence of patient findings; and the needs and preferences of the patient. Global Rationale: Evidence-based practice (EBP) is defined as the practice of nursing in which the nurse makes clinical decisions on the basis of the best available current research evidence; clinical expertise, including internal evidence of patient findings; and the needs and preferences of the patient. Studying healthcare provider’s orders and asking colleagues to identify best care approaches are not steps within the evidence-based practice process. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values 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; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Define evidence-based practice (EBP) MNL Learning Outcome: Page Number: 19-20
Question 11 Type: MCSA The nurse manager is explaining evidence-based practice (EBP) to the staff during a weekly meeting. Which statement should the manager use when explaining this approach to care? 1. “EBP expedites the assessment phase of the nursing process.” 2. “EBP is a problem-solving approach to clinical practice questions.” 3. “EBP is quicker than using the nursing process when providing patient care.” 4. “EBP demonstrates an interest in furthering the development of nursing science.” Correct Answer: 2 Rationale 1: EBP does not alter or influence any phase within the nursing process. Rationale 2: EBP is a problem-solving approach to clinical practice questions. Rationale 3: EBP is not used instead of the nursing process. Rationale 4: EBP is not used to demonstrate an interest in furthering the development of nursing science. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: EBP is a problem-solving approach to clinical practice questions. EBP does not alter or replace any phase or step of the nursing process. EBP is not used to demonstrate an interest in furthering the development of nursing science. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values 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; Knowledge; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Define evidence-based practice (EBP). MNL Learning Outcome: Page Number: 20
Question 12 Type: MCMA The Board of Directors for a major healthcare organization asks the Department of Patient Care Services to implement evidence-based practice. What reasons did the board most likely use to make this recommendation? Standard Text: Select all that apply. 1. Rising cost for healthcare 2. Requests by the nursing staff 3. Expectation to do the right thing 4. Reduced numbers of hospital inpatients 5. Desire to engage in quality improvement Correct Answer: 1, 3, 5 Rationale 1: The rising cost of healthcare is one reason that a climate for the evolution of evidence-based health care has been created. Rationale 2: Requests by nursing staff is not necessarily a factor that has led to the board’s decision by creating a climate for the evolution of evidence-based health care. Rationale 3: The management principle of doing things right is one reason that a climate for the evolution of evidence-based health care has been created. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The reduced numbers of hospital inpatients would not impact the decision to implement evidence-based practice. Rationale 5: The desire for quality improvement is one reason that a climate for the evolution of evidence-based health care has been created. Global Rationale: Rising health costs, the management principle of doing things right and the desire for quality improvement have created a climate for the evolution of evidence-based health care. It is unlikely that the board has made this decision based upon requests by the nursing staff. The numbers of inpatients in the hospital would not impact the decision to implement evidencebased practice. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.C.3. Value the concept of EBP as integral to determining best clinical practice AACN Essentials Competencies: III.8. Acquire an understanding of the process for how nursing and related healthcare quality and safety measures are developed, validated, and endorsed NLN Competencies: Knowledge and Science; Knowledge; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Define evidence-based practice (EBP). MNL Learning Outcome: Page Number: 20
Question 13 Type: MCSA The nurse is identifying external evidence to be used when implementing evidence-based practice for a patient’s care. What should the nurse use as external evidence? 1. Textbooks 2. Research studies 3. Standardized care plans 4. Patient teaching materials Correct Answer: 2 Rationale 1: Textbooks are not a source for external evidence. Rationale 2: External evidence comes from well-designed research studies. Rationale 3: Standardized care plans are not a source for external evidence. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Patient teaching materials are not a source for external evidence. Global Rationale: External evidence comes from well-designed research studies. Textbooks, standardized care plans, and patient teaching materials are not sources for external evidence. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values AACN Essentials Competencies: III.1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the components of EBP. MNL Learning Outcome: Page Number: 20
Question 14 Type: MCSA The nurse reviews quality improvement results and outcomes evaluations before selecting evidence-based practice interventions for a patient’s care. What information is the nurse using? 1. Issue of interest 2. Internal evidence 3. External evidence 4. Patient population Correct Answer: 2 Rationale 1: Issue of interest is used to design the clinical question. Rationale 2: Internal evidence is derived from quality improvement and outcomes evaluations. Rationale 3: External evidence comes from well-designed research studies. Rationale 4: The patient population is used to design the clinical question. Global Rationale: Internal evidence is derived from quality improvement and outcomes evaluations. External evidence comes from well-designed research studies. The issue of interest and the patient population are used to design the clinical question. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.2. Describe EBP to include the components of research evidence, clinical expertise and patient/family values AACN Essentials Competencies: III.1. Explain the interrelationships among theory, practice and research NLN Competencies: Knowledge and Science; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the components of EBP. MNL Learning Outcome: Page Number: 20
Question 15 Type: MCSA The nurse is concluding actions taken when using evidence-based practice approaches to plan a patient’s care. What should the nurse do to ensure that the planned care is of the highest quality? 1. Incorporate patient preferences and values 2. Transcribe the plan of care into the Kardex 3. Ask the manager to review the final plan of care 4. Discuss the plan of care with the healthcare provider Correct Answer: 1 Rationale 1: Incorporating patient preferences and values provides individualization and is the benchmark for quality nursing care. Rationale 2: Transcribing the plan of care into the Kardex does not ensure that the planned care is of the highest quality. Rationale 3: Asking the manager to review the final plan of care does not ensure that the planned care is of the highest quality. Rationale 4: Discussing the plan of care with the healthcare provider does not ensure that the planned care is of the highest quality. Global Rationale: Incorporating patient preferences and values provides individualization and is the benchmark for quality nursing care. Transcribing the plan of care or asking the manager or healthcare provider to review the plan of care does not ensure that the planned care is of the highest quality.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence 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; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify the components of EBP. MNL Learning Outcome: Page Number: 20
Question 16 Type: MCMA The nurse is planning to use evidence-based practice to plan a patient’s care. What actions should the nurse include when using this approach? Standard Text: Select all that apply. 1. Review internal evidence 2. Identify external evidence 3. Discuss patient preferences 4. Consider individual expertise 5. Analyze costs associated with care Correct Answer: 1, 2, 3, 4 Rationale 1: EBP has been described as a problem-solving approach for clinical practice that includes the three foundational legs of external evidence, clinical expertise and internal evidence, and patient preferences and values. Rationale 2: EBP has been described as a problem-solving approach for clinical practice that includes the three foundational legs of external evidence, clinical expertise and internal evidence, and patient preferences and values. Rationale 3: EBP has been described as a problem-solving approach for clinical practice that includes the three foundational legs of external evidence, clinical expertise and internal evidence, and patient preferences and values.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: EBP has been described as a problem-solving approach for clinical practice that includes the three foundational legs of external evidence, clinical expertise and internal evidence, and patient preferences and values. Rationale 5: Analysis of the costs for care is not a part of the evidence-based practice process. Global Rationale: EBP has been described as a problem-solving approach for clinical practice that includes the three foundational legs of external evidence, clinical expertise and internal evidence, and patient preferences and values. Analysis of the costs for care is not a part of the evidence-based practice process. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence 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; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify the components of EBP. MNL Learning Outcome: Page Number: 20
Question 17 Type: MCSA The nurse is determining the best internal evidence to use when planning evidence-based interventions for a patient’s care. What should the nurse take into consideration when making this determination? 1. Opinions of authorities and reports of expert committees 2. Systematic reviews of descriptive and qualitative studies 3. Systematic reviews or meta-analyses of randomized controlled trials 4. Comparison of patient assessment and evaluation with quality improvement and outcome evaluations Correct Answer: 4 Rationale 1: Opinions of authorities and reports of expert communities describe Level VII external evidence. Rationale 2: Systematic reviews of descriptive and qualitative studies describe Level V external evidence. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Systematic reviews or meta-analyses of randomized controlled trials describe Level I external evidence. Rationale 4: Internal evidence is the incorporation of patient assessments and evaluations with quality improvement and outcomes evaluations. Global Rationale: Internal evidence is the incorporation of patient assessments and evaluations with quality improvement and outcomes evaluations. Opinions of authorities and reports of expert committees, systematic reviews of descriptive and qualitative studies, and systematic reviews or meta-analyses of randomized controlled trials are various levels of external evidence. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence 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; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Describe internal evidence and patient preferences in relationship to EBP. MNL Learning Outcome: Page Number: 20
Question 18 Type: MCMA What should a nurse who is reviewing interventions for a patient’s health problem keep in mind when selecting applicable interventions? Standard Text: Select all that apply. 1. Length of stay 2. Medical diagnosis 3. Patient experience 4. Patient circumstances 5. Prescribed treatments Correct Answer: 3, 4 Rationale 1: Length of stay is not used to influence a nurse’s choice of interventions with evidence-based practice. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Medical diagnosis is not used to influence a nurse’s choice of interventions with evidence-based practice. Rationale 3: It is the patient experience and circumstances that influence a nurse’s choice of nursing intervention. Rationale 4: It is the patient experience and circumstances that influence a nurse’s choice of nursing intervention. Rationale 5: Prescribed treatments are not used to influence a nurse’s choice of interventions with evidence-based practice. Global Rationale: It is the patient experience and circumstances that influence a nurse’s choice of nursing intervention. Length of stay, medical diagnosis, and prescribed treatments are not used to influence a nurse’s choice of interventions with evidence-based practice. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence 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; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Describe internal evidence and patient preferences in relationship to EBP. MNL Learning Outcome: Page Number: 20
Question 19 Type: MCSA The nurse is a member of the quality improvement committee within a healthcare organization. What action indicates that the information from this committee is being used to support evidence-based practice? 1. Quality improvement indicators address the largest volume of patient safety hazards. 2. Outcomes from quality improvement studies supersede patient preferences and values. 3. Committee participants support the use of evidence-based practice when planning patient care. 4. Results from quality improvement studies are being used as internal evidence for interventions. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 4 Rationale 1: Addressing the largest volume of patient safety hazards does not indicate that the information from the committee is being used to support evidence-based practice. Rationale 2: Using the outcomes to supersede patient preferences and values does not indicate that the information from the committee is being used to support evidence-based practice. Rationale 3: Personal opinion regarding the use of evidence-based practice does not indicate that the information from the committee is being used to support this problem solving approach. Rationale 4: Internal evidence is derived from quality improvement evaluations. Using the results from quality improvement studies as internal evidence for interventions indicates that the information from this committee is being used to support evidence-based practice. Global Rationale: Internal evidence is derived from quality improvement evaluations. Addressing the largest volume of patient safety hazards, using outcomes to supersede patient preferences, or personal opinions regarding the use of evidence-based practice do not indicate that the information from the committee is being used to support evidence-based practice. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence 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; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe internal evidence and patient preferences in relationship to EBP. MNL Learning Outcome: Page Number: 20
Question 20 Type: MCSA The nurse manager determines that a staff nurse planned quality care for an assigned patient. What did the manager observe to come to this conclusion? 1. Incorporation of patient preferences 2. Accurate calculation of intake and output 3. Delegation of tasks to unlicensed assistive personnel 4. Logging out of the computer system after documenting LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: The incorporation of patient preferences and values to individualize care is a benchmark for quality nursing care. Rationale 2: Accurately calculating intake and output does not necessarily mean quality care was planned. Rationale 3: Delegating tasks to unlicensed assistive personnel does not indicate that quality care was planned. Rationale 4: Logging out of the computer system after documenting does not indicate that quality care was planned. Global Rationale: The incorporation of patient preferences and values to individualize care is a benchmark for quality nursing care. Calculating intake and output, delegating tasks, and logging out of the computer system do not necessarily indicate that the nurse planned quality care for the patient. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.3. Base individualized care plan on patient values, clinical expertise and evidence 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; Knowledge; Defining how the evidence on which practice is based is developed and by whom Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Describe internal evidence and patient preferences in relationship to EBP. MNL Learning Outcome: Page Number: 20
Question 21 Type: MCSA The nurse is having difficulty identifying keywords to use when searching a database for evidence-based practice interventions. What should the nurse use to help with the identification of keywords? 1. The nursing process 2. Terms from the PICOT question 3. Identified levels for external evidence LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. NANDA-approved nursing diagnoses phrases Correct Answer: 2 Rationale 1: The nursing process is not identified as an approach to identify keywords when searching a database for evidence-based practice interventions. Rationale 2: The terms from the PICOT question may be used as keywords. Rationale 3: Levels for external evidence are not identified as an approach to identify keywords when searching a database for evidence-based practice interventions. Rationale 4: NANDA-approved nursing diagnosis phrases are not identified as an approach to identify keywords when searching a database for evidence-based practice interventions. Global Rationale: The terms from the PICOT question may be used as keywords. The nursing process, levels for external evidence, and nursing diagnosis phrases are not identified as approaches to identify keywords when searching a database for evidence-based practice interventions. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.4. Describe reliable sources for locating evidence reports and clinical practice guidelines AACN Essentials Competencies: III.4. Evaluate the credibility of sources of information, including but not limited to databases and Internet resources NLN Competencies: Context and Environment; Knowledge; access and search of databases Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. List important citation sources used to locate appropriate external evidence MNL Learning Outcome: Page Number: 21-22
Question 22 Type: MCSA The nurse desires to obtain as much information about clinical guidelines as possible in preparation for an educational program on evidence-based practice. Which database should the nurse use to achieve this goal? 1. Cochrane Collaboration 2. National Guideline Clearinghouse 3. PubMed from the National Library of Medicine 4. Cumulative Index of Nursing and Allied Health Literature (CINAHL) LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2 Rationale 1: The Cochrane Collaboration is a large database that requires the user to register. Rationale 2: The National Guideline Clearinghouse provides an open access database of clinical guidelines. Rationale 3: PubMed from the National Library of Medicine is a large database. Rationale 4: The Cumulative Index of Nursing and Allied Health Literature (CINAHL) is a large database. Global Rationale: The National Guideline Clearinghouse provides an open access database of clinical guidelines. PubMed from the National Library of Medicine, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and the Cochrane Collaboration are large databases. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 4. Describe reliable sources for locating evidence reports and clinical practice guidelines AACN Essentials Competencies: III. 4. Evaluate the credibility of sources of information, including but not limited to databases and Internet resources NLN Competencies: Context and Environment; Knowledge; access and search of databases Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. List important citation sources used to locate appropriate external evidence MNL Learning Outcome: Page Number: 22
Question 23 Type: MCMA The nurse needs to access the Cumulative Index of Nursing and Allied Health Literature (CINAHL). Where should the nurse go to access this database? Standard Text: Select all that apply. 1. Public library 2. Medical school library 3. Library within the hospital 4. Public school district library 5. Library at the local university LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1, 2, 3, 5 Rationale 1: Subscriptions may be needed to access some benefits of databases. Academic libraries as well as many medical and hospital libraries maintain such subscriptions. Public libraries may also have access. Rationale 2: Subscriptions may be needed to access some benefits of databases. Academic libraries as well as many medical and hospital libraries maintain such subscriptions. Public libraries may also have access. Rationale 3: Subscriptions may be needed to access some benefits of databases. Academic libraries as well as many medical and hospital libraries maintain such subscriptions. Public libraries may also have access. Rationale 4: Public school district libraries are not identified as having access to these types of databases. Rationale 5: Subscriptions may be needed to access some benefits of databases. Academic libraries as well as many medical and hospital libraries maintain such subscriptions. Public libraries may also have access. Global Rationale: Subscriptions may be needed to access some benefits of databases. Academic libraries as well as many medical and hospital libraries maintain such subscriptions. Public libraries may also have access. Public school district libraries are not identified as having access to these types of databases. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.4. Describe reliable sources for locating evidence reports and clinical practice guidelines AACN Essentials Competencies: III. 4. Evaluate the credibility of sources of information, including but not limited to databases and Internet resources NLN Competencies: Context and Environment; Knowledge; access and search of databases Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. List important citation sources used to locate appropriate external evidence. MNL Learning Outcome: Page Number: 22
Question 24 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
While preparing for a clinical conference the nurse accesses the computer for evidence-based practice information. What information indicates that the nurse used the National Guideline Clearinghouse? 1. Opinions of experts who have cared for patients with similar problems 2. Copies of clinical guidelines that address a patient’s particular problems 3. Results of descriptive studies performed on patients with similar problems 4. Analyses of controlled trials conducted with patients having similar problems Correct Answer: 2 Rationale 1: Opinions of experts would be obtained from a database search. Rationale 2: The National Guideline Clearinghouse provides an open access database of clinical guidelines. Rationale 3: Results of descriptive studies would be obtained from a database search. Rationale 4: Analyses of controlled trials would be obtained from a database search. Global Rationale: The National Guideline Clearinghouse provides an open access database of clinical guidelines. Expert opinion, descriptive study results, and analyses of controlled trials would be obtained from a database search. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.4. Describe reliable sources for locating evidence reports and clinical practice guidelines AACN Essentials Competencies: III.4. Evaluate the credibility of sources of information, including but not limited to databases and Internet resources NLN Competencies: Context and Environment; Knowledge; access and search of databases Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. List important citation sources used to locate appropriate external evidence. MNL Learning Outcome: Page Number: 22
Question 25 Type: MCMA The nurse is comparing the nursing process with the research process. Which steps should the nurse identify as being similar? Standard Text: Select all that apply. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Set goals 2. Analyze the data 3. Evaluate the results 4. Collect data for evidence 5. Determine nursing diagnoses Correct Answer: 1, 2, 3, 4 Rationale 1: For both processes goals are set, data is analyzed, results are evaluated, and data is collected for evidence. Rationale 2: For both processes goals are set, data is analyzed, results are evaluated, and data is collected for evidence. Rationale 3: For both processes goals are set, data is analyzed, results are evaluated, and data is collected for evidence. Rationale 4: For both processes goals are set, data is analyzed, results are evaluated, and data is collected for evidence. Rationale 5: Determining nursing diagnoses is a part of the nursing process. Global Rationale: For both processes goals are set, data is analyzed, results are evaluated, and data is collected for evidence. Determining nursing diagnoses is a part of the nursing process. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Compare and contrast the steps of the nursing and evidence-based practice processes. MNL Learning Outcome: Page Number: 21
Question 26 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is reviewing steps performed within the research process. Which actions indicate that the nurse worked through the step equivalent to the nursing diagnosis phase of the nursing process? Standard Text: Select all that apply. 1. Analyzed results 2. Collected information 3. Chose an appropriate theory 4. Conducted a literature review 5. Identified a research question Correct Answer: 3, 4 Rationale 1: Analyzing results is comparable to the evaluation phase of the nursing process. Rationale 2: Collecting information is comparable to the implementation phase of the nursing process. Rationale 3: Conducting a literature review and choosing an appropriate theory are actions of the research process that are comparable to the nursing diagnosis phase of the nursing process. Rationale 4: Conducting a literature review and choosing an appropriate theory are actions of the research process that are comparable to the nursing diagnosis phase of the nursing process. Rationale 5: Identifying a research question is comparable to the assessment phase of the nursing process. Global Rationale: Conducting a literature review and choosing an appropriate theory are actions of the research process that are comparable to the nursing diagnosis phase of the nursing process. Analyzing results is comparable to the evaluation phase of the nursing process. Collecting information is comparable to the implementation phase of the nursing process. Identifying a research question is comparable to the assessment phase of the nursing process. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Compare and contrast the steps of the nursing and evidence-based practice processes. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 21
Question 27 Type: MCMA The nurse is completing the evaluation phase of the nursing process. What actions should the nurse perform that would be comparable to using the research process? Standard Text: Select all that apply. 1. Analyzing results 2. Reporting findings 3. Conducting analysis 4. Conducting literature review 5. Identifying a research question Correct Answer: 1, 2, 3 Rationale 1: Conducting an analysis, analyzing results, and reporting findings are actions within the research process that are comparable to the evaluation phase of the nursing process. Rationale 2: Conducting an analysis, analyzing results, and reporting findings are actions within the research process that are comparable to the evaluation phase of the nursing process. Rationale 3: Conducting an analysis, analyzing results, and reporting findings are actions within the research process that are comparable to the evaluation phase of the nursing process. Rationale 4: Conducting a literature review is comparable to the nursing diagnosis phase of the nursing process. Rationale 5: Identifying a research question is comparable to the assessment phase of the nursing process. Global Rationale: Conducting an analysis, analyzing results, and reporting findings are actions within the research process that are comparable to the evaluation phase of the nursing process. Conducting a literature review is comparable to the nursing diagnosis phase of the nursing process. Identifying a research question is comparable to the assessment phase of the nursing process. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare and contrast the steps of the nursing and evidence-based practice processes. MNL Learning Outcome: Page Number: 21
Question 28 Type: MCMA The nurse is participating in the research process. Which actions indicate that the nurse successfully completed the identification of a research question? Standard Text: Select all that apply. 1. The nurse analyzed results. 2. The nurse reported findings. 3. The nurse conducted a literature review. 4. The nurse utilized knowledge of nursing. 5. The nurse reflected on clinical experiences. Correct Answer: 4, 5 Rationale 1: Analyzing results is a part of the final phase of the research process. Rationale 2: Reporting findings is a part of the final phase of the research process. Rationale 3: Conducting a literature review is a part of the problem/purpose identification. Rationale 4: When identifying a research question, the nurse should utilize nursing knowledge and clinical experiences. Rationale 5: When identifying a research question, the nurse should utilize nursing knowledge and clinical experiences. Global Rationale: When identifying a research question, the nurse should utilize nursing knowledge and clinical experiences. Analyzing results is a part of the final phase of the research process. Reporting findings is a part of the final phase of the research process. Conducting a literature review is a part of the problem/purpose identification. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Compare and contrast the steps of the nursing and evidence-based practice processes. MNL Learning Outcome: Page Number: 21
Question 29 Type: MCSA The nurse decides that a clinical guideline would be helpful when planning the care of a patient. What should the nurse do to obtain this guideline? 1. Access a nursing literature database 2. Search through a nursing procedure textbook 3. Telephone a clinical guidelines company for assistance 4. Conduct a computer search on a clinical guidelines website Correct Answer: 4 Rationale 1: Accessing a nursing literature database will not provide the needed information on clinical guidelines. Rationale 2: Searching through a nursing procedure textbook would be time consuming. Rationale 3: Telephoning a clinical guidelines company for assistance would be time consuming. Rationale 4: To obtain clinical guideline information, the nurse should conduct a search on a clinical guidelines website. Global Rationale: To obtain clinical guideline information, the nurse should conduct a search on a clinical guidelines website. Accessing a nursing literature database will not provide the needed information on clinical guidelines. Searching through a nursing procedure textbook or telephoning a clinical guidelines company for assistance would be time consuming. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: III.B.5. Locate evidence reports related to clinical practice topics and guidelines AACN Essentials Competencies: IV.6. Evaluate data from all relevant sources, including technology, to inform the delivery of care NLN Competencies: Knowledge and Science; Knowledge; Electronic databases; literature retrieval; evaluating data for validity and reliability; evidence and best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss the role of information technology in the evidence-based practice process. MNL Learning Outcome: Page Number: 21-22
Question 30 Type: MCSA The nurse is reviewing content from the PICOT question format to identify terms to search when accessing information from a database. Which content should the nurse use as keyword(s) for this search? 1. Outcome 2. Assessment 3. Patient home address 4. Patient discharge plan Correct Answer: 1 Rationale 1: PICOT is an acronym for terms to be included in the clinical question. These terms include patient population, intervention or issue of interest, comparison intervention or group, outcome, and time frame. Rationale 2: Assessment is not a part of the PICOT format. Rationale 3: Patient home address is not a part of the PICOT format. Rationale 4: Patient discharge plan is not a part of the PICOT format. Global Rationale: PICOT is an acronym for terms to be included in the clinical question. These terms include patient population, intervention or issue of interest, comparison intervention or group, outcome, and time frame. Assessment, patient home address, and patient discharge plan are not parts of the PICOT format. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: III.B.5. Locate evidence reports related to clinical practice topics and guidelines AACN Essentials Competencies: IV.6. Evaluate data from all relevant sources, including technology, to inform the delivery of care NLN Competencies: Knowledge and Science; Knowledge; Electronic databases; literature retrieval; evaluating data for validity and reliability; evidence and best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss the role of information technology in the evidence-based practice process. MNL Learning Outcome: Page Number: 20
Question 31 Type: MCSA The nurse is writing a paper on a research project as part of a class assignment. What should the nurse do to obtain the most current information about the research topic? 1. Ask the librarian to identify journals appropriate for the research topic. 2. Discuss ideas and content with classmates for inclusion in the research project. 3. Access a database and search for information appropriate for the research topic. 4. Study the class research textbook for information that would apply to the research topic. Correct Answer: 3 Rationale 1: Asking the librarian for help might not be time efficient. Rationale 2: Discussing ideas and content with classmates is not the most appropriate approach. Rationale 3: The nurse should access a database and search for information appropriate for the research topic. Rationale 4: The class research textbook might not have information appropriate for the research topic. Global Rationale: The nurse should access a database and search for information appropriate for the research topic. Asking the librarian for help might not be time efficient. Discussing ideas and content with classmates is not the most appropriate approach. The class research textbook might not have information appropriate for the research topic. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.5. Locate evidence reports related to clinical practice topics and guidelines LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IV.6. Evaluate data from all relevant sources, including technology, to inform the delivery of care NLN Competencies: Knowledge and Science; Knowledge; Electronic databases; literature retrieval; evaluating data for validity and reliability; evidence and best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss the role of information technology in the evidence-based practice process. MNL Learning Outcome: Page Number: 22
Question 32 Type: MCSA The nurse needs to locate external evidence to support evidence-based practice interventions for a patient’s care. What action indicates that the nurse maximized the use of technology to locate this evidence? 1. The nurse focused the search on appropriate and applicable nursing diagnoses. 2. The nurse identified specific data points when searching a clinical guidelines website. 3. The nurse input medical subject heading terms when searching through a database. 4. The nurse emphasized the expected patient outcomes when searching through a database. Correct Answer: 3 Rationale 1: Focusing on nursing diagnoses may or may not provide the nurse with the needed information. Rationale 2: Focusing on data points may or may not provide the nurse with the needed information. Rationale 3: Effective literature searching is a necessary foundation to locating appropriate external evidence. Selection of an appropriate database is central to efficient literature searching. Use of medical subject heading (MeSH) terms expedites the searching process. Rationale 4: Focusing on patient outcomes may or may not provide the nurse with the needed information. Global Rationale: Effective literature searching is a necessary foundation to locating appropriate external evidence. Selection of an appropriate database is central to efficient literature searching. Use of medical subject heading (MeSH) terms expedites the searching process. Focusing on nursing diagnoses, data points, or patient outcomes may or may not provide the nurse with the needed information. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Management of Care QSEN Competencies: III.B.5. Locate evidence reports related to clinical practice topics and guidelines AACN Essentials Competencies: IV.6. Evaluate data from all relevant sources, including technology, to inform the delivery of care NLN Competencies: Knowledge and Science; Knowledge; Electronic databases; literature retrieval; evaluating data for validity and reliability; evidence and best practices for nursing Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss the role of information technology in the evidence-based practice process. MNL Learning Outcome: Page Number: 22
Question 33 Type: SEQ The nurse is conducting a qualitative research study. In which order should the nurse complete the steps of the research process? Standard Text: Click and drag the options below to move them up or down. 1. Develop overall approach 2. Identify problem of interest 3. Confirm and close the study 4. Develop emergent research design 5. Interpret data throughout the study Correct Answer: 2, 1, 4, 3, 5 Rationale 1: This step occurs second, after the problem is identified. Rationale 2: This step occurs first. Rationale 3: This step occurs fourth, after the overall approach is developed. Rationale 4: This step occurs third, after the emergent research design is developed. Rationale 5: This is the final step in the process. Global Rationale: When conducting a qualitative research study the nurse should identify the problem of interest, develop the overall approach, develop the emergent research design, confirm and close the study, and interpret the data throughout the study. Cognitive Level: Application Client Need: Safe and Effective Care Environment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the essential steps of the research process and common statistical methods used in nursing evidence. MNL Learning Outcome: Page Number: 22
Question 34 Type: MCSA The nurse is analyzing outcomes at the conclusion of a quantitative research study. On which variable is the nurse focusing? 1. Dependent 2. Conceptual 3. Operational 4. Independent Correct Answer: 1 Rationale 1: The dependent variable is the presumed effect from the manipulation of the independent variable. In other words, the dependent variable is often the outcome of interest. Rationale 2: The conceptual variable defines the qualities of the variable of interest. Rationale 3: The operational variable describes how a variable is measured. Rationale 4: The independent variable is the reason for the change in the outcome. Global Rationale: The dependent variable is the presumed effect from the manipulation of the independent variable. In other words, the dependent variable is often the outcome of interest. The conceptual variable defines the qualities of the variable of interest. The operational variable describes how a variable is measured. The independent variable is the reason for the change in the outcome. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the essential steps of the research process and common statistical methods used in nursing evidence. MNL Learning Outcome: Page Number: 22-23
Question 35 Type: MCSA The nurse is designing a study to determine why some patients with diabetes develop foot ulcers while others do not. When reviewing this research question, what should the nurse highlight as the sample population? 1. Patients with diabetes 2. Foot ulcer development 3. Patients with foot ulcers 4. Patients without foot ulcers Correct Answer: 1 Rationale 1: The sample is the most accessible group of the population. For this research question the most accessible group of the population would be patients with diabetes. Rationale 2: Ulcer development is the outcome. Rationale 3: Patients may have foot ulcers but not have diabetes. Rationale 4: There is no reason for the nurse to study patients without foot ulcers. Global Rationale: The sample is the most accessible group of the population. For this research question the most accessible group of the population would be patients with diabetes. Patients may have foot ulcers but not have diabetes. There is no reason for the nurse to study patients without foot ulcers. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A. 1. Demonstrate knowledge of basic scientific methods and processes LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the essential steps of the research process and common statistical methods used in nursing evidence MNL Learning Outcome: Page Number: 23
Question 36 Type: MCSA The nurse is designing a quantitative research project where the data will be collected at one point in time. Which type of data collection process is the nurse planning to use? 1. Prospective 2. Longitudinal 3. Retrospective 4. Cross-sectional Correct Answer: 4 Rationale 1: Prospective data collection is the collection of data about variables that are occurring at the time of the data collection. Rationale 2: Longitudinal data collection occurs at two or more points in time. Rationale 3: Retrospective is the collection of data about variables that have already occurred. Rationale 4: Cross-sectional data collection occurs at one point in time. Global Rationale: Cross-sectional data collection occurs at one point in time. Prospective data collection is the collection of data about variables that are occurring at the time of the data collection. Longitudinal data collection occurs at two or more points in time. Retrospective is the collection of data about variables that have already occurred. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes AACN Essentials Competencies: III.2. Demonstrate an understanding of the basic elements of the research process and models for applying evidence to clinical practice LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Knowledge and Science; Knowledge; Elements of the research process and methods of scientific inquiry Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 9. Describe the essential steps of the research process and common statistical methods used in nursing evidence. MNL Learning Outcome: Page Number: 23
Question 37 Type: MCSA The nurse is evaluating the success of using evidence-based interventions for patient care. What should the nurse do to determine if these interventions were successful? 1. Analyze outcomes 2. Review plan of care 3. Strategize actions to delegate 4. Identify use of pain medication Correct Answer: 1 Rationale 1: It is important to measure outcomes to determine the impact of EBP change. Rationale 2: Reviewing the plan of care will not help the nurse determine if evidence-based interventions were successful. Rationale 3: Strategizing actions to delegate will not help the nurse determine if evidence-based interventions were successful. Rationale 4: Identifying the use of pain medications will not help the nurse determine if evidence-based interventions were successful. Global Rationale: It is important to measure outcomes to determine the impact of EBP change. Reviewing the plan of care, strategizing actions to delegate, or identifying the use of pain medication will not help the nurse determine if evidence-based interventions were successful. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.7. Question rationale for routine approaches to care that result in less-than-desired outcomes or adverse events 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; Knowledge; Defining the relationships between research and science building, and between research and EBP LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe common steps to implementing EBP in medical-surgical nursing. MNL Learning Outcome: Page Number: 24
Question 38 Type: MCSA The nurse is implementing evidence-based practice when providing patient care. Which action indicates that the nurse implemented this process appropriately? 1. The nurse ended the process by formulating a searchable question. 2. The nurse formulated a searchable question before searching the literature. 3. The nurse applied the result to clinical practice before searching the literature. 4. The nurse evaluated the outcomes of applied evidence before appraising the literature. Correct Answer: 2 Rationale 1: Formulating a searchable question is not the last step in the process. Rationale 2: The nurse should formulate a searchable question before searching the literature. Rationale 3: The literature should be searched before applying the result to clinical practice. Rationale 4: The literature should be appraised before evaluating the outcomes of applied evidence. Global Rationale: The literature should be searched before applying the result to clinical practice. Formulating a searchable question is the first step in the process. The literature should be searched before applying the result to clinical practice and evaluating the outcomes of applied evidence. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.6. Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care 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; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe common steps to implementing EBP in medical-surgical nursing. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 24
Question 39 Type: MCSA The nurse is evaluating outcomes from evidence-based interventions provided to a patient with chronic obstructive lung disease. Which outcome indicates that a positive change occurred in this patient? 1. Patient set a date to quit smoking. 2. Patient uses emergency bronchodilator every 4 hours. 3. Patient states that antibiotics are to be taken until all symptoms subside. 4. Patient explains that adverse effects of prescribed medications are to be expected. Correct Answer: 1 Rationale 1: When evaluating outcomes, the goal is positive changes in patient outcomes that impact healthcare quality. Smoking cessation in the patient with chronic obstructive lung disease would be a positive change that impacts the quality of healthcare. Rationale 2: Using emergency bronchodilators indicates that the patient is poorly controlled. Rationale 3: Stating that antibiotics are to be taken until symptoms subside indicates the need for additional teaching about infection control measures. Rationale 4: Adverse effects of medications are not to be expected. This indicates that additional teaching is required. Global Rationale: When evaluating outcomes, the goal is positive changes in patient outcomes that impact healthcare quality. Smoking cessation in the patient with chronic obstructive lung disease would be a positive change that impacts the quality of healthcare. Using emergency bronchodilators indicates that the patient is poorly controlled. Stating that antibiotics are to be taken until symptoms subside indicates the need for additional teaching about infection control measures. Adverse effects of medications are not to be expected. This indicates that additional teaching is required. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities AACN Essentials Competencies: III.6. Integrate evidence, clinical judgment, interprofessional perspectives and patient preferences in planning, implementing, and evaluating outcomes of care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Knowledge and Science; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 10. Describe common steps to implementing EBP in medical-surgical nursing. MNL Learning Outcome: 5.9.4. Utilize the nursing process in care of client. Page Number: 24
Question 40 Type: SEQ The manager is designing a presentation to introduce the nursing staff to the implementation of evidence-based practice. In which order should the manager explain the steps of this process? Standard Text: Click and drag the options below to move them up or down. 1. Evaluate the outcomes 2. Search the literature efficiently 3. Appraise the literature critically 4. Formulate a searchable question 5. Apply the result to clinical practice or patient Correct Answer: 4, 2, 3, 5, 1 Rationale 1: This is the last step in the process. Rationale 2: This occurs after the searchable question is formulated. Rationale 3: This occurs after the literature has been searched. Rationale 4: This is the first step in the process. Rationale 5: This occurs after the literature has been appraised. Global Rationale: The steps to implementing evidence-based practice in nursing are as follows: 1) Formulate a searchable question. 2) Search the literature efficiently. 3) Appraise the literature critically. 4) Apply the result to clinical practice or patient. 5) Evaluate the outcomes of the applied evidence in the practice or patient. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.B.1. Participate effectively in appropriate data collection and other research activities LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Knowledge; Defining the relationships between research and science building, and between research and EBP Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Describe common steps to implementing EBP in medical-surgical nursing. MNL Learning Outcome: Page Number: 24
Question 41 Type: MCMA The nurse is reviewing the Institute of Medicine’s framework for healthcare that leads to practical improvements. Which qualities should the nurse identify as being supported by this framework? Standard Text: Select all that apply. 1. Safety 2. Timeliness 3. Cost reduction 4. Patient-centeredness 5. Elimination of healthcare-associated infections Correct Answer: 1, 2, 4 Rationale 1: The Institute of Medicine has described a framework for healthcare that can lead to practical improvements. It emphasizes safety, effectiveness, patient centeredness, timeliness, equity, and efficiency. Rationale 2: The Institute of Medicine has described a framework for healthcare that can lead to practical improvements. It emphasizes safety, effectiveness, patient centeredness, timeliness, equity, and efficiency. Rationale 3: Cost reduction has not been identified by the Institute of Medication’s framework for practical improvements in healthcare. Rationale 4: The Institute of Medicine has described a framework for healthcare that can lead to practical improvements. It emphasizes safety, effectiveness, patient centeredness, timeliness, equity, and efficiency. Rationale 5: Elimination of healthcare-associated infections has not been identified by the Institute of Medication’s framework for practical improvements in healthcare. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The Institute of Medicine has described a framework for healthcare that can lead to practical improvements. It emphasizes safety, effectiveness, patient centeredness, timeliness, equity, and efficiency. Cost reduction and elimination of healthcare-associated infections have not been identified by the Institute of Medication’s framework for practical improvements in healthcare. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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.9. Apply quality improvement processes to effectively implement patient safety initiatives and monitor performance measures, including nurse-sensitive indicators in the microsystem of care NLN Competencies: Knowledge and Science; Knowledge; Relationships between knowledge/science and quality and safe patient care Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Discuss ethical considerations in EBP. MNL Learning Outcome: Page Number: 25
Question 42 Type: MCSA The manager is concerned that a staff nurse is not appropriately implementing evidence-based practice with patient care. What did the manager observe to come to this conclusion? 1. Clinical expertise is included. 2. Patient situations are individualized. 3. Data is researched before implementing. 4. Interventions are applied to all patients assigned. Correct Answer: 4 Rationale 1: Clinical expertise is a component of EBP. Rationale 2: Individualizing patient situations is a component of EBP. Rationale 3: Researching data is a component of EBP. Rationale 4: EBP is meant to be applied at the local level; it is not to be generalized like research.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: EBP is meant to be applied at the local level; it is not to be generalized like research. Clinical expertise, individualized patient situations, and researching data are components of EBP. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III A.1. Demonstrate knowledge of basic scientific methods and processes 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; Knowledge; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Discuss ethical considerations in EBP MNL Learning Outcome: Page Number: 25
Question 43 Type: MCSA Prior to implementing evidence-based interventions when providing patient care, the nurse reviews the actions for scientific value. What is the purpose of this nurse’s action? 1. Maximizing the utilization of resources 2. Ensuring the actions are applied at the global level 3. Ensuring that activities are worth doing to be ethical 4. Guaranteeing that the patient will not have an untoward effect Correct Answer: 3 Rationale 1: Maximizing the utilization of resources is not an action when determining scientific value. Rationale 2: Ensuring actions are applied at the global level is not an action when determining scientific value. Rationale 3: When ensuring the scientific value of an evidence-based intervention, the nurse is making sure that the activity is worth doing to be ethical. Rationale 4: Guaranteeing that the patient will not have an untoward effect is not an action when determining scientific value. Global Rationale: When ensuring the scientific value of an evidence-based intervention, the nurse is making sure that the activity is worth doing to be ethical. Maximizing the utilization of LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
resources, ensuring actions are applied at the global level, and guaranteeing that the patient will not have an untoward effect are not actions to determine scientific value. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III A.1. Demonstrate knowledge of basic scientific methods and processes 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; Knowledge; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Discuss ethical considerations in EBP MNL Learning Outcome: Page Number: 25
Question 44 Type: MCSA The nurse learns that topical medication and heat have been used to treat stage 3 pressure ulcers. What should the nurse consider before implementing this treatment approach? 1. How long the heat should be applied to the area 2. If the patient can withstand the application of heat 3. What medication should be used in the wound bed 4. If the treatment approach is ethical and evidence-based Correct Answer: 4 Rationale 1: If this were an evidence-based approach, the length of time to apply the heat would be defined. Rationale 2: This is not an evidence-based intervention for wound care. Questioning if the patient can withstand heat is not appropriate. Rationale 3: If this were an evidence-based approach, the medication to use in the wound bed would be defined. Rationale 4: EBP has a basis in ethical principles. However, not all approaches used to improve quality are evidenced based or ethical. Global Rationale: EBP has a basis in ethical principles. However, not all approaches used to improve quality are evidenced based or ethical. Evidence-based approaches would provide all LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
necessary information such as length of time to apply heat and medication to use in the wound bed. Questioning if the patient can withstand the application of heat to the area is not appropriate. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: III.A.1. Demonstrate knowledge of basic scientific methods and processes 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; Knowledge; Defining what is evidence-based practice Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 11. Discuss ethical considerations in EBP MNL Learning Outcome: Page Number: 25
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 3 Question 1 Type: MCSA When planning holistic care for a patient admitted with heart failure, what should the nurse include? 1. spiritual needs 2. measuring intake and output 3. daily weights 4. ambulating with assistance Correct Answer: 1 Rationale 1: Holistic health care is based on the concept of wellness. When planning holistic care for a patient, the nurse needs to consider psychosocial, cultural, spiritual, and intellectual needs in addition to physical needs. Rationale 2: Measuring intake and output meets the patient’s physical needs and would not address holistic needs. Rationale 3: Daily weights focus solely on the patient’s physical needs and would not address holistic needs. Rationale 4: Ambulating with assistance focuses solely on the patient’s physical needs and would not address holistic needs. Global Rationale: Holistic health care is based on the concept of wellness. When planning holistic care for a patient, the nurse needs to consider psychosocial, cultural, spiritual, and intellectual needs in addition to physical needs. Measuring intake and output, daily weights, and ambulating with assistance focus solely on the patient’s physical needs and would not address holistic needs. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; Knowledge; Factors that contribute to or threaten health Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Define health and discuss factors affecting the health of individuals, families, and communities. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 6.8.4. Utilize the nursing process in care of client. Page Number: 28 Question 2 Type: MCSA A patient tells the nurse that he has been fortunate since he has never experienced any major illnesses and has enjoyed good health without much effort. How should the nurse realize this patient is defining “good health?” 1. the absence of disease 2. effortless 3. fortunate 4. an integrated method of functioning Correct Answer: 1 Rationale 1: The patient is defining “good health” as being the absence of disease since he states being fortunate for not experiencing any major illnesses and not expending much effort to do so. Rationale 2: The nurse has no way of knowing if the patient believes “good health” is effortless. Rationale 3: The nurse has no way of knowing if the patient believes “good health” is effortless. Rationale 4: An integrated method of functioning is the definition of wellness which the patient is not describing. Global Rationale: The patient is defining “good health” as being the absence of disease since he states being fortunate for not experiencing any major illnesses and not expending much effort to do so. The nurse has no way of knowing if the patient believes “good health” is effortless. An integrated method of functioning is the definition of wellness which the patient is not describing.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; Knowledge; Factors that contribute to or threaten health Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: Page Number: 28 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 3 Type: MCSA A patient tells the nurse that he often is concerned with his declining mobility status even though he continues to experience no major health issues. When planning care according to the wellness framework, what should the nurse include for this patient? 1. interventions to restore the patient’s mobility status 2. activities to promote the current level of functioning 3. suggestions to maintain the patient’s current mobility status 4. activities to help the patient cope with the decline in mobility status Correct Answer: 1 Rationale 1: Providing care based on a framework of wellness facilitates active involvement by both the nurse and the patient in promoting, maintaining, or restoring health. Because the patient is concerned with declining mobility status, the nurse should include interventions to help restore this status for the patient. Rationale 2: Activities to promote the current level of functioning would not support wellness care. Rationale 3: Providing suggestions to maintain the patient’s current mobility status would not support wellness care. Rationale 4: Helping the patient cope with the decline in mobility status would not support wellness care. Global Rationale: Providing care based on a framework of wellness facilitates active involvement by both the nurse and the patient in promoting, maintaining, or restoring health. Because the patient is concerned with declining mobility status, the nurse should include interventions to help restore this status for the patient. Activities to promote the current level of functioning, providing suggestions to maintain the patient’s current mobility status, and helping the patient cope with the decline in mobility status would also not support wellness care.
Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; Knowledge; Factors that contribute to or threaten health Nursing/Integrated Concepts: Nursing Process: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: Page Number: 28 Question 4 Type: MCSA The nurse has provided care to a patient according to the concept of wellness. Which outcome indicates that care has been successful for this patient? 1. The patient is returning home with adjustments in the home environment to support a temporary alteration in mobility status. 2. The patient needs additional teaching to understand the reason for taking Coumadin at the same time every day. 3. The patient is not independent with personal care and will need assistance when at home. 4. The patient is easily fatigued and will need assistance with meal preparation and medication administration. Correct Answer: 1 Rationale 1: Providing care based on a framework of wellness facilitates active involvement by both the nurse and the patient in promoting, maintaining, or restoring health. Returning home with adjustments to support an alteration in mobility status demonstrates that the patient received care to restore health. Rationale 2: The patient who needs additional teaching for Coumadin needs additional intervention to maintain health. Rationale 3: The patient who needs assistance with personal care needs interventions to promote health. Rationale 4: The patient who is easily fatigued and needs assistance with meals and medications needs interventions to promote and restore health. Global Rationale: Providing care based on a framework of wellness facilitates active involvement by both the nurse and the patient in promoting, maintaining, or restoring health. Returning home with adjustments to support an alteration in mobility status demonstrates that the patient received care to restore health. The patient who needs additional teaching for Coumadin needs additional intervention to maintain health. The patient who needs assistance with personal care needs interventions to promote health. The patient who is easily fatigued and needs assistance with meals and medications also needs interventions to promote and restore health. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Knowledge; Factors that contribute to or threaten health Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: Page Number: 28 Question 5 Type: MCSA 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 Correct Answer: 1 Rationale 1: Chronic illnesses that are associated with genetic makeup include sickle cell disease, hemophilia, diabetes mellitus, and cancer. Rationale 2: Hypertension is associated with a cultural group. Rationale 3: Osteoporosis is associated with a cultural group. Rationale 4: Myocardial infarction is associated with age and lifestyle factors. Global Rationale: Chronic illnesses that are associated with genetic makeup include sickle cell disease, hemophilia, diabetes mellitus, and cancer. Hypertension and osteoporosis are associated with a cultural group. Myocardial infarction is associated with age and lifestyle factors. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 28 Question 6 Type: MCSA The nurse is assessing a patient who is a Native American. For which health problem should the nurse be alert? 1. diabetes mellitus 2. eye disorders 3. hypertension 4. osteoporosis Correct Answer: 1 Rationale 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. Rationale 2: Eye disorders are more common in Chinese Americans. Rationale 3: Hypertension is more common in African Americans. Rationale 4: Osteoporosis is more common in Caucasian women of small stature and Scandinavian heritage. Global Rationale: 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. Eye disorders are more common in Chinese Americans. Hypertension is more common in African Americans. Osteoporosis is more common in Caucasian women of small stature and Scandinavian heritage. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: 10.5.1. Explain the incidence, prevalence, and pathophysiology for diabetes. Page Number: 28 Question 7 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA During an assessment, a patient tells the nurse that she is lactose intolerant. The nurse realizes that this food intolerance is common within which cultural groups? 1. Mexican Americans 2. Scandinavian Americans 3. Indian Americans 4. Mediterranean Americans Correct Answer: 1 Rationale 1: Most Mexican Americans, African Americans, Native Americans, and Asians are lactose intolerant. Rationale 2: Lactose intolerance is not common in Scandinavian Americans. Rationale 3: Lactose intolerance is not common in Indian Americans. Rationale 4: Lactose intolerance is not common in Mediterranean Americans. Global Rationale: Most Mexican Americans, African Americans, Native Americans, and Asians are lactose intolerant. Lactose intolerance is not common in Scandinavian Americans, Indian Americans, or Mediterranean Americans. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: 11.1.4. Utilize the nursing process in care of client. Page Number: 29 Question 8 Type: MCSA A patient is admitted with a respiratory illness. During the assessment, the nurse learns the patient is a factory worker and uses public transportation to get to work. Which will be impacted by the patient’s socioeconomic status? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. lifestyle 2. cognitive abilities 3. education level 4. developmental level Correct Answer: 1 Rationale 1: Lifestyle and environmental influences are affected by one’s income level. Rationale 2: Cognitive development affects whether people view themselves as healthy or ill and may affect their health practices. Rationale 3: Educational level affects the ability to understand and follow guidelines for health. Rationale 4: Developmental level is not related to socioeconomic status. Global Rationale: Lifestyle and environmental influences are affected by one’s income level. Cognitive development affects whether people view themselves as healthy or ill and may affect their health practices. Educational level affects the ability to understand and follow guidelines for health. Developmental level is not related to socioeconomic status. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 1. Define health and discuss factors affecting the health of individuals, families, and communities. MNL Learning Outcome: 5.1.1. Explain the pathophysiology of infectious/inflammatory disorders of the upper respiratory system. Page Number: 29 Question 9 Type: MCSA The nurse is collecting data at the immunization clinic. Which disclosure by the patient would cause the nurse to withhold the administration of the varicella vaccine? 1. a blood transfusion after undergoing surgery 3 months ago 2. history of an allergic reaction to yeast bread LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. itching and swelling on the face and hands after ingesting eggs 4. a low-grade temperature within the past 2 days Correct Answer: 1 Rationale 1: Contraindications for the varicella vaccine include pregnancy, suppressed immunity, and a recent history of a blood transfusion. Rationale 2: An allergy to yeast does not indicate a potential difficulty with the administration of the varicella vaccine. Rationale 3: An allergy to eggs does not indicate a potential difficulty with the administration of the varicella vaccine. Rationale 4: Recent hyperthermia does not indicate a potential difficulty with the administration of the varicella vaccine. Global Rationale: Contraindications for the varicella vaccine include pregnancy, suppressed immunity, and a recent history of a blood transfusion. Recent hyperthermia and allergy to yeast or eggs do not indicate a potential difficulty with the administration of the varicella vaccine. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss the nurse’s role in health promotion. MNL Learning Outcome: 2.1.1. Utilize the nursing process in care of client. Page Number: 35 Question 10 Type: MCMA 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? Standard Text: Select all that apply. 1. Eliminating preventable disease, disability, injury, and premature death 2. Achieving health equity, eliminating disparities, and improving the health of all groups LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1,2,3,4 Rationale 1: Eliminating preventable disease, disability, injury, and premature death is one of the Healthy People 2020 goals and should be included in the presentation. Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: Healthy People 2020 goals include eliminating preventable disease, disability, injury, and premature death; achieving health equity, eliminating disparities, and improving the health of all groups; creating social and physical environments that promote good health for all; and promoting healthy development and healthy behaviors across every stage of life. 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. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the nurse’s role in health promotion. MNL Learning Outcome: Page Number: 34 Question 11 Type: MCSA The nurse is instructing a patient on nutritional needs by using MyPlate. What should the nurse emphasize when using this food guide? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 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. Rationale 2: MyPlate was not created to instruct patients on ways to limit exposure to carcinogens. Rationale 3: MyPlate was not created to reduce the onset of diabetes mellitus. Rationale 4: MyPlate was not created to avoid the overuse of aerobic exercise. Global Rationale: 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. This is what the nurse should emphasize when instructing the patient. MyPlate was not created to instruct patients on ways to limit exposure to carcinogens, reduce the onset of diabetes mellitus, or avoid the overuse of aerobic exercise. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the nurse’s role in health promotion. MNL Learning Outcome: 11.1.1. Explain the causes, risk factors, incidence, and pathophysiology of obesity and malnutrition. Page Number: 33 Question 12 Type: MCSA A female patient asks the nurse for suggestions to help her improve her health. What should the nurse instruct this patient? 1. Participate in a continuous physical activity for 30 minutes 5 or more days each week.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Obtain sun exposure every day. 3. Reduce tobacco use. 4. Sleep at least 6 hours each night. Correct Answer: 1 Rationale 1: Practices for healthy living include participating in a continuous physical activity for 30 minutes 5 or more days each week. Rationale 2: Sun exposure should be limited and should always involve application of a sunscreen. Rationale 3: Smoking and the use of tobacco products should be eliminated, not just reduced. Rationale 4: The patient should be instructed to sleep 7 to 8 hours each day. Global Rationale: Practices for healthy living include participating in a continuous physical activity for 30 minutes 5 or more days each week. This is what the nurse should instruct the patient. Sun exposure should be limited and should always involve application of a sunscreen. Smoking and the use of tobacco products should be eliminated, not just reduced. The patient should be instructed to sleep 7 to 8 hours each day. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss the nurse’s role in health promotion. MNL Learning Outcome: Page Number: 33 Question 13 Type: MCSA During an assessment, a patient tells the nurse that he drinks four alcoholic beverages every day and smokes one pack of cigarettes. The nurse realizes that these chemical agents can predispose the patient to develop: 1. a disease. 2. an illness. 3. an injury. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. an infection. Correct Answer: 1 Rationale 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. Rationale 2: An illness is a person’s response to a disease and is highly individualized. Rationale 3: There is not enough information to determine if the alcohol and cigarettes will cause the patient to develop an injury. Rationale 4: There is not enough information to determine if the alcohol and cigarettes will cause the patient to develop an infection. Global Rationale: 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. An illness is a person’s response to a disease and is highly individualized. There is not enough information to determine if the alcohol and cigarettes will cause the patient to develop an injury or an infection. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Differentiate between disease and illness. MNL Learning Outcome: Page Number: 35 Question 14 Type: MCSA A patient tells the nurse that she has been relatively healthy until recently, which is why she made an appointment to see the physician. The nurse realizes that the primary reason individuals seek health care is for which problem? 1. pain 2. bleeding 3. vomiting LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. fatigue Correct Answer: 1 Rationale 1: The subjective symptom of pain is the primary reason people seek health care. Rationale 2: Bleeding is an objective symptom that varies with the disease process. Rationale 3: Vomiting is an objective symptom that varies with the disease process. Rationale 4: Fatigue is a subjective symptom that varies with the disease process. Global Rationale: The subjective symptom of pain is the primary reason people seek health care. Bleeding and vomiting are objective symptoms that vary with the disease process. Fatigue is a subjective symptom that also varies with the disease process. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.C.9. Recognize that patient expectations influence outcomes in management of pain or suffering. AACN Essentials Competencies: IX.8. 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: 4. Differentiate between disease and illness. MNL Learning Outcome: Page Number: 35 Question 15 Type: MCSA While being treated for one disease process, a patient begins demonstrating manifestations of another disease process. The nurse realizes that the patient is experiencing which type of disease? 1. iatrogenic 2. communicable 3. congenital 4. degenerative Correct Answer: 1 Rationale 1: An iatrogenic disease is caused by medical therapy.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: A communicable disease spreads from one person to another. Rationale 3: A congenital disease exists at or before birth. Rationale 4: A degenerative disease results from the deterioration or impairment of organs or tissues. Global Rationale: An iatrogenic disease is caused by medical therapy. A communicable disease spreads from one person to another. A congenital disease exists at or before birth. A degenerative disease results from the deterioration or impairment of organs or tissues. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Differentiate between disease and illness. MNL Learning Outcome: Page Number: 37 Question 16 Type: MCSA A patient tells the nurse that he feels fine even though he has been told he has 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 Correct Answer: 1 Rationale 1: An illness is a person’s response to a disease. The person responds to his or her own perception of the disease and to the perception of others. The patient has been told he has chronic kidney failure and is likely to manifest signs of an illness. Rationale 2: An iatrogenic disease is caused by medical therapy. Rationale 3: Psychosomatic illnesses are characterized by physiologic symptoms caused by mental or emotional disturbance. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: An idiopathic disorder has no known cause. Global Rationale: An illness is a person’s response to a disease. The person responds to his or her own perception of the disease and to the perception of others. The patient has been told he has chronic kidney failure and is prone to manifesting signs of an illness. An iatrogenic disease is caused by medical therapy. Psychosomatic illnesses are characterized by physiologic symptoms caused by mental or emotional disturbance. An idiopathic disorder has no known cause. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Differentiate between disease and illness. MNL Learning Outcome: Page Number: 35 Question 17 Type: MCSA A patient has not been feeling well for a few days and has been using an over-the-counter medication without improvement. The nurse understands that the patient is demonstrating which illness behavior? 1. seeking medical care 2. experiencing symptoms 3. assuming the sick role 4. assuming a dependent role Correct Answer: 1 Rationale 1: The patient is talking with a nurse about not feeling well, which describes the behavior of seeking medical care. Rationale 2: Experiencing symptoms occurs when the patient realizes he is not feeling well. Rationale 3: Assuming the sick role occurs after seeking medical care. Rationale 4: Assuming a dependent role occurs upon hospitalization.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The patient is talking with a nurse about not feeling well, which describes the behavior of seeking medical care. Experiencing symptoms occurs when the patient realizes he is not feeling well. Assuming the sick role occurs after seeking medical care. Assuming a dependent role occurs upon hospitalization. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 37 Question 18 Type: MCSA A patient wants to be discharged to home and resume normal activities of daily living. The nurse realizes the patient is entering which stage of illness behaviors? 1. achieving recovery and rehabilitation 2. seeking medical care 3. assuming a dependent role 4. experiencing symptoms Correct Answer: 1 Rationale 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. Rationale 2: Seeking medical care occurs when the patient sees a healthcare provider for diagnosis of an illness. Rationale 3: The patient assumes a dependent role when entering the hospital for care. Rationale 4: Experiencing symptoms is the first stage of an acute illness. Global Rationale: Achieving recovery and rehabilitation is the final stage of an acute illness and occurs when the patient give up the dependent role and resumes normal activities and responsibilities. Seeking medical care occurs when the patient sees a healthcare provider for diagnosis of an illness. The patient assumes a dependent role when entering the hospital for care. Experiencing symptoms is the first stage of an acute illness. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 37 Question 19 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Patients with a chronic illness need to learn how to manage an ongoing treatment plan even in periods of remission. The nurse should explain that the treatment plan is the reason the patient is not experiencing any symptoms and encourage the patient not to stop the plan. Rationale 2: The nurse should not encourage the patient to stop the treatment plan by agreeing that it is a good idea. Rationale 3: The nurse should not say that the plan can always be resumed if the symptoms return. Rationale 4: The nurse should not suggest that the patient make any alterations in the treatment plan such as weaning off the plan. Global Rationale: Patients with a chronic illness need to learn how to manage an ongoing treatment plan even in periods of remission. The nurse should explain that the treatment plan is the reason the patient is not experiencing any symptoms and encourage the patient not to stop the plan. The nurse should not encourage the patient to stop the treatment plan by agreeing that it is a good idea or say that the plan can always be resumed if the symptoms return. The nurse should not suggest that the patient make any alterations in the treatment plan such as weaning off the plan. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.C.1. Value seeing health care 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 38 Question 20 Type: MCSA 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 the patient in ways to minimize the impact of the chronic illness on activities of daily living. 2. Encourage the patient to seek medical care with any changes in symptoms. 3. Limit activities until symptoms subside. 4. Suggest lifestyle alterations to prepare for more challenging symptom management in the future. Correct Answer: 1 Rationale 1: Nursing interventions for the person with a chronic illness focus on education to promote independent functioning, reduce healthcare costs, and improve well-being and quality of life. The nurse should instruct the patient in ways to minimize the impact of the chronic illness on activities of daily living. Rationale 2: Encouraging the patient to seek medical care with any changes in symptoms does not support independent functioning. Rationale 3: Limiting activities until symptoms subside does not improve well-being and quality of life. Rationale 4: Suggesting lifestyle alterations to prepare for more challenging symptom management in the future does not improve well-being or quality of life. Global Rationale: Nursing interventions for the person with a chronic illness focus on education to promote independent functioning, reduce healthcare costs, and improve well-being and quality of life. The nurse should instruct the patient in ways to minimize the impact of the chronic illness on activities of daily living. The other choices do not support independent functioning, reduce healthcare costs, or improve well-being and quality of life. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.C.1. Value seeing health care 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 38 Question 21 Type: MCSA The nurse is planning an education session to discuss primary levels of disease prevention. Which topics should the nurse include in this presentation? 1. the elimination of smoking and alcohol use 2. available locations for diabetes screening 3. the need for annual colonoscopy examinations 4. the use of available community rehabilitation facilities Correct Answer: 1 Rationale 1: Primary prevention involves activities to prevent illness and disease and includes smoking cessation and abstinence from alcohol. Rationale 2: Screening activities such as glucose testing are a form of secondary prevention. Rationale 3: Screening activities such as colonoscopy examinations are a form of secondary prevention. Rationale 4: Rehabilitation activities are considered a tertiary level of prevention. Global Rationale: Primary prevention involves activities to prevent illness and disease and includes smoking cessation and abstinence from alcohol. Screening activities such as glucose testing and colonoscopy examinations are a form of secondary prevention. Rehabilitation activities are considered a tertiary level of prevention. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 38 Question 22 Type: MCSA During a routine physical examination, a 52-year-old Caucasian male declines to have his prostate gland examined and states he does not have a family history and does not feel he is at risk. What initial response by the nurse is most appropriate? 1. “Your risk factors increase with aging.” 2. “You may refuse any screening test you wish.” 3. “I will need to tell the physician about your refusal.” 4. “You are right. Caucasian men have a lower incidence of prostate cancer.” Correct Answer: 1 Rationale 1: The need for prostate screening begins at age 50. Individuals with risk factors should begin screening at age 45. The patient’s age places him at an increased risk, so he should begin the screening process. Rationale 2: While the patient may refuse testing, refusal limits the patient’s engagement in further testing in the event that a disease process is occurring within the prostate gland. Rationale 3: The patient’s refusal should be recorded in the medical record but not used as a means to coerce the patient. Rationale 4: Even though the risk is reduced in Caucasian males, the nurse should not agree that the patient does not need the screening test. Global Rationale: The need for prostate screening begins at age 50. Individuals with risk factors should begin screening at age 45. The patient’s age places him at an increased risk, so he should begin the screening process. While the patient may refuse testing, refusal limits the patient’s engagement in further testing in the event that a disease process is occurring within the prostate gland. The patient’s refusal should be recorded in the medical record but not used as a means to coerce the patient. Even though the risk is reduced in Caucasian males, the nurse should not agree that the patient does not need the screening test. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: 13.7.1. Explain the incidence, risk factors, and pathophysiology for male reproductive disorders. Page Number: 36 Question 23 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Instructing in self-examination of the breasts is a secondary-level intervention. Rationale 3: Screening for glaucoma is a secondary-level intervention. Rationale 4: Counseling on healthy nutrition is a primary-level intervention. Global Rationale: 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. Instructing in selfexamination of the breasts and screening for glaucoma are secondary-level interventions. Counseling on healthy nutrition is a primary-level intervention. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 38 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 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 his or her former state of health as soon as possible. This includes receiving treatment such as antibiotic therapy for an infection. Rationale 2: Primary activities promote health and delay the occurrence of disease. Rationale 3: Tertiary interventions focus on stopping the disease process and returning the individual to society within the constraints of a disability. Rationale 4: There is no acute level of intervention. Global Rationale: 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 his or her former state of health as soon as possible. This includes receiving treatment such as antibiotic therapy for an infection. Primary activities promote health and delay the occurrence of disease. Tertiary interventions focus on stopping the disease process and returning the individual to society within the constraints of a disability. There is no acute level of intervention. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: 9.3.3. Examine the diagnosis and treatment of ear disorders. Page Number: 38 Question 25 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A 45-year-old patient voices concerns about gaining 12 pounds over the past 2 years. The patient reports no change in 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.” Correct Answer: 1 Rationale 1: Weight gain is common in middle adulthood, usually the result of continuing to consume the same number of calories while decreasing physical activity. Rationale 2: Asking the patient about exercise fails to provide the needed information and assumes the patient is sedentary. Rationale 3: Implying the patient is overeating is judgmental and will do little to establish therapeutic rapport. Rationale 4: The patient is aware of aging, and pointing this out does little to meet the patient’s obvious interest in more information. Global Rationale: Weight gain is common in middle adulthood, usually the result of continuing to consume the same number of calories while decreasing physical activity. Asking the patient about exercise fails to provide the needed information and assumes the patient is sedentary. Implying the patient is overeating is judgmental and will do little to establish therapeutic rapport. The patient is aware of aging, and pointing this out does little to meet the patient’s obvious interest in more information. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: 11.1.1. Explain the causes, risk factors, incidence, and pathophysiology of obesity and malnutrition. Page Number: 31 Question 26 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is assisting an 18-year-old female patient to strategize ways to avoid the onset of disease with aging. What should the nurse include in this plan? Standard Text: 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. Correct Answer: 1,2,3 Rationale 1: Behavioral patterns established in young adulthood impact the risk for many chronic diseases more commonly diagnosed in middle or late adulthood, including obesity, coronary heart disease, diabetes, chronic lung disease, and chronic liver disease. Health promotion for young adults must include teaching about healthy behaviors and eating habits associated with reduced risk for developing cancers and chronic diseases. This includes teaching about maintaining a healthy weight. Rationale 2: Behavioral patterns established in young adulthood also impact the risk for many chronic diseases more commonly diagnosed in middle or late adulthood, including obesity, coronary heart disease, diabetes, chronic lung disease, and chronic liver disease. Health promotion for young adults must include teaching about healthy behaviors associated with reduced risk for developing cancers and chronic diseases. This includes avoiding tobacco products. Rationale 3: Behavioral patterns established in young adulthood also impact the risk for many chronic diseases more commonly diagnosed in middle or late adulthood, including obesity, coronary heart disease, diabetes, chronic lung disease, and chronic liver disease. Health promotion for young adults must include teaching about healthy behaviors associated with reduced risk for developing cancers and chronic diseases. This includes avoiding substance abuse. Rationale 4: Annual mammograms would not apply until the patient reaches the age of 40. Rationale 5: Colonoscopies would not apply until the patient reaches the age of 50. Global Rationale: Behavioral patterns established in young adulthood also impact the risk for many chronic diseases more commonly diagnosed in middle or late adulthood, including obesity, coronary heart disease, diabetes, chronic lung disease, and chronic liver disease. Health promotion for young adults must include teaching about healthy behaviors and eating habits associated with reduced risk for developing cancers and chronic diseases. This includes teaching about maintaining a healthy weight as well as avoiding tobacco products and substance abuse. Annual mammograms would not apply until the patient reaches the age of 40. Colonoscopies would not apply until the patient reaches the age of 50. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: Page Number: 30 Question 27 Type: MCSA A 45-year-old woman 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. Ensure an adequate intake of calcium. 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. Correct Answer: 1 Rationale 1: The middle-aged adult is at risk for developing osteoporosis. Ensuring an adequate calcium intake will help prevent the onset of this health problem. Rationale 2: Women should begin having annual mammograms by age 40. Rationale 3: Blood pressure should be measured annually and more frequently if elevated. Rationale 4: Exercise recommendations are for 30 minutes 5 or more days each week. Global Rationale: The middle-aged adult is at risk for developing osteoporosis. Ensuring an adequate calcium intake will help prevent the onset of this health problem. Women should begin having annual mammograms by age 40. Blood pressure should be measured annually and more frequently if elevated. Exercise recommendations are for 30 minutes 5 or more days each week. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: Page Number: 31 Question 28 Type: MCSA A 75-year-old patient tells the nurse about experiencing extreme drowsiness after taking an over-the-counter cold medication. The nurse notes the patient ingested the prescribed amount of the medication. 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. Correct Answer: 1 Rationale 1: Older patients often experience altered responses to medications because of age-related changes in the kidneys and liver. Rationale 2: There is no evidence the patient has taken too much medication. Rationale 3: There is no information provided to indicate the patient is taking other medications. Rationale 4: Allergic reactions typically manifest with integumentary- or respiratory-related symptoms. Global Rationale: Older patients often experience altered responses to medications because of age-related changes in the kidneys and liver. There is no evidence the patient has taken too much medication. There is no information to indicate the patient is taking other medications. Allergic reactions typically manifest with integumentary- or respiratory-related symptoms. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.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; LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: Page Number: 33 Question 29 Type: MCMA The nurse is preparing discharge instructions for a 63-year-old African American male 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? Standard Text: Select all that apply. 1. hypertension 2. sickle cell anemia 3. lactose intolerance 4. diabetes 5. osteoporosis Correct Answer: 1,2,3,4 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 5: Caucasian women of small stature and of Scandinavian heritage have a higher risk of developing osteoporosis. Global Rationale: 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, sickle cell anemia, LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
lactose intolerance, and diabetes among African Americans. Caucasian women of small stature and of Scandinavian heritage have a higher risk of developing osteoporosis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.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: 1. Define health and discuss factors affecting the health of individuals, families, and communities MNL Learning Outcome: Page Number: 29 Question 30 Type: MCMA A 20-year-old female nursing student has never been exposed to measles, mumps, or rubella, or received a vaccine; her last tetanus immunization was 4 years ago; and she received the tetanus, diphtheria, and pertussis vaccines as a child. She has never been vaccinated or exposed to varicella, human papillomavirus (HPV), or hepatitis. According to the recommended immunizations for adults, which immunizations should the nurse recommend the student receive at this time? Standard Text: Select all that apply. 1. measles, mumps, rubella (MMR) 2. hepatitis B 3. HPV 4. influenza 5. tetanus, diphtheria, pertussis Correct Answer: 1,2,3,4 Rationale 1: MMR is recommended for those entering college. Rationale 2: Hepatitis B is recommended for those in the healthcare field. Rationale 3: HPV is recommended for females under age 26. Rationale 4: Influenza vaccination is recommended annually for all adults. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: The student had a tetanus immunization 4 years ago, and the recommendation is for a booster every 10 years; she was vaccinated as a child. Global Rationale: MMR is recommended for those entering college. Hepatitis B is recommended for those in the healthcare field. HPV is recommended for females under age 26. Influenza vaccination is recommended annually for all adults. The student had a tetanus immunization 4 years ago, and the recommendation is for a booster every 10 years; she was vaccinated as a child. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.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: 3. Discuss the nurse’s role in health promotion. MNL Learning Outcome: Page Number: 35 Question 31 Type: SEQ 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. Standard Text: Click and drag the options below to move them up or down. 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 Correct Answer: 1,4,3,2,5 Rationale 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. Rationale 2: In the commonly recognized sequence of illness behaviors, assuming a dependent role is the fourth. Rationale 3: In the commonly recognized sequence of illness behaviors, seeking medical care is the third. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: In the commonly recognized sequence of illness behaviors, assuming the sick role is the second. Rationale 5: In the commonly recognized sequence of illness behaviors, recovery and rehabilitation are the fifth. Global Rationale: Illness behaviors are the way people cope with the alterations in health and function caused by a disease. The sequence of commonly recognized illness behaviors is experiencing symptoms, assuming the sick role, seeking health care, assuming a dependent role, and recovery and rehabilitation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; health promotion/disease prevention Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: Page Number: 35 Question 32 Type: MCMA The overall mission of Healthy People 2020 is to improve the nation’s health. What topics are addressed to achieve this goal? Standard Text: Select all that apply. 1. access to health services 2. nutrition and weight status 3. reproductive health 4. injury and violence 5. outpatient surgery Correct Answer: 1,2,3,4 Rationale 1: Access to health services is a health indicator used in Healthy People 2020. Rationale 2: Nutrition and weight status are health indicators used in Healthy People 2020. Rationale 3: Reproductive health is a health indicator used in Healthy People 2020.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Injury and violence are health indicators used in Healthy People 2020. Rationale 5: Outpatient surgery is not among the specific topics addressed in Healthy People 2020. Global Rationale: Access to health services, nutrition and weight status, reproductive health, and injury and violence are health indicators used in Healthy People 2020. Outpatient surgery is not among the specific topics addressed in Healthy People 2020. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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: 4. Differentiate between disease and illness. MNL Learning Outcome: Page Number: 34 Question 33 Type: MCSA 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 Correct Answer: 1 Rationale 1: A congenital disease or disorder exists at or before birth; a chronic disease is one that requires continuing management over a long period. Rationale 2: An acute disease has a rapid onset; a chronic disease requires continuing management over a long period. Rationale 3: A communicable disease can be spread from one person to another; a functional disease affects function but does not have organic causes. Rationale 4: An idiopathic disease has an unknown cause; an iatrogenic disease is caused by medical therapy. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: A congenital disease or disorder exists at or before birth; a chronic disease is one that requires continuing management over a long period. An acute disease has a rapid onset; a chronic disease requires continuing management over a long period. A communicable disease can be spread from one person to another; a functional disease affects function but does not have organic causes. An idiopathic disease has an unknown cause; an iatrogenic disease is caused by medical therapy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: 7.7.3. Examine the diagnosis and treatment options for seizure disorders. Page Number: 37 Question 34 Type: MCMA A nurse is conducting an educational session on self-care initiatives for chronic heart failure patients and their support persons prior to discharge from the hospital. Which topics should be included in the discussion? Standard Text: Select all that apply. 1. Adapting activities of daily living 2. Maintaining a sense of hope 3. Maintaining a feeling of being in control 4. Living as normally as possible 5. Seeking third and often fourth opinions Correct Answer: 1,2,3,4 Rationale 1: Patients with chronic illnesses experience chronic diseases in different ways, but in general will need to adapt activities of daily living to their abilities. Rationale 2: Patients with chronic illnesses experience chronic diseases in different ways, but in general will need to maintain a sense of hope. Rationale 3: Patients with chronic illnesses need to feel in control. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Patients with chronic illnesses need to live as normally as possible. Rationale 5: While seeking third and often fourth opinions might be a topic that interests patients, it is not a priority for patient education. Global Rationale: Patients with chronic illnesses experience chronic diseases in different ways, but in general will need to adapt activities of daily living to their abilities, maintain a sense of hope and of feeling in control, and live as normally as possible. While seeking third and often fourth opinions might be a topic that interests patients, it is not a priority for patient education. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1.Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; chronic disease management Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: 6.8.4. Utilize the nursing process in care of client. Page Number: 38 Question 35 Type: MCSA 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 Correct Answer: 1 Rationale 1: Genetic testing is primary prevention in that it determines genetically linked diseases before they develop. Rationale 2: Mammograms and self-breast exams are examples of secondary prevention. Rationale 3: Taking lipid reducing agents to treat a specific disease is also secondary prevention.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Supporting research is tertiary level prevention that helps in stopping the disease through research efforts. Global Rationale: Genetic testing is primary prevention in that it determines genetically linked diseases before they develop. Mammograms, breast self-exams, and taking lipid-reducing agents to treat a specific disease are examples of secondary prevention. Supporting research is tertiary-level prevention that helps in stopping the disease through research efforts. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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: 5. Describe illness behaviors and needs of the patient with acute illness and chronic illness. MNL Learning Outcome: 13.1.1. Explain the risk factors, causes, and pathophysiology of benign breast disorders and breast cancer. Page Number: 38
Question 36 Type: MCMA Which statement by a 52-year-old female patient admitted for evaluation of migraines reflects the changes that occur in middle adulthood? Standard Text: 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.” Correct Answer: 1,2,3,4 Rationale 1: This statement reflects the changes and concerns that arise in the middle adult years. Rationale 2: This statement reflects the changes and concerns that arise in the middle adult years. Rationale 3: This statement reflects the changes and concerns that arise in the middle adult years. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: This statement reflects the changes and concerns that arise in the middle adult years. Rationale 5: While unplanned pregnancy can be a concern for perimenopausal women, this statement is more likely to come from a young adult. Global Rationale: The first four statements reflect the changes and concerns that arise in the middle adult years. While unplanned pregnancy can be a concern for perimenopausal women, this statement is more likely to come from a young adult. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: Page Number: 31 Question 37 Type: MCMA A 50-year-old African American male is being seen by his primary healthcare provider for an annual physical. His last complete physical was 2 years ago and he has no complaints at this time. He asks what health screening tests he should expect now that he is 50 years old, in addition to his annual health examination. Based on the patient’s age and ethnicity, which screening tests should the nurse review with the patient? Standard Text: Select all that apply. 1. cholesterol level 2. colonoscopy and occult blood screening 3. prostate cancer screening 4. vision screening 5. osteoporosis screening Correct Answer: 1,2,3,4 Rationale 1: This screening test is recommended for the middle-aged male based on age and time interval. Rationale 2: This screening test is recommended for the middle-aged male based on age and time interval. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: This screening test is recommended for the middle-aged male based on age and time interval. Rationale 4: This screening test is recommended for the middle-aged male based on age and time interval. Rationale 5: Osteoporosis screening is recommended for the older adult male (age 65 or older). Global Rationale: All of these screening tests, except for osteoporosis screening, are recommended for the middle-aged male based on age and time interval. Osteoporosis screening is recommended for the older adult male (age 65 or older). Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: Page Number: 36 Question 38 Type: MCMA The nurse is caring for an older patient experiencing confusion and lethargy after taking routine doses of medication. Which age-related changes should the nurse identify that could predispose this patient to toxic drug effects? Standard Text: 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 Correct Answer: 1,2,3,4 Rationale 1: Changes in tissue and organ structure contribute to a predisposition to toxic drug effects. Rationale 2: Reduced liver function contributes to a predisposition to toxic drug effects. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Taking several drugs at once contributes to a predisposition to toxic drug effects. Rationale 4: Reduced renal function contributes to a predisposition to toxic drug effects. Rationale 5: A decrease in taste sensation is an age-related change but it does not contribute to toxic drug effects. Global Rationale: Changes in tissue and organ structure, reduced liver and renal function, and taking several drugs at once contribute to a predisposition to toxic drug effects. A decrease in taste sensation is an age-related change but it does not contribute to toxic drug effects. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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. Compare and contrast health risks, assessment, and health promotion for the young adult, middle adult, and older adult. MNL Learning Outcome: Page Number: 33
Question 39 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 1: For people with chronic illnesses, the goal of the PCMH is to provide comprehensive care with a focus on preventing acute disease crises. Rationale 2: One facet of the PCMH is increased preventive services. Rationale 3: Health insurance billing is not a facet of this care delivery model. Rationale 4: PCMH is designed to provide comprehensive and coordinated patient and family care. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: The PCMH is a primary care model that focuses on all levels of illness prevention. Global Rationale: For people with chronic illnesses, the goal of the PCMH is to provide comprehensive care with a focus on preventing acute disease crises. One facet of the PCMH is increased preventive services. PCMH is designed to provide comprehensive and coordinated patient and family care. The patient-centered medical home is a primary care model that focuses on all levels of illness prevention. Health insurance billing is not a facet of this care delivery model. Cognitive Level: Application Client Need: Health Promotion and Maintenance Client Need Sub: 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: 6. Describe essential elements and goals of coordinated primary care models such as the Transitional Care Model and the Patient-Centered Medical Home. MNL Learning Outcome: 10.5.3. Examine the diagnosis, monitoring, treatment options, and complications for diabetes. Page Number: 39
Question 40 Type: MCMA 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? Standard Text: Select all that apply. 1. Disease process 2. Daily monitoring 3. Medication management 4. Transfer to long-term care 5. Frequency of hospitalization Correct Answer: 1, 2, 3 Rationale 1: In the disease management model the focus is on education about the disease. Rationale 2: In the disease management model the focus is on self-monitoring. Rationale 3: In the disease management model the focus is on management. Rationale 4: Transferring to long-term care is not a focus in the disease management model. Rationale 5: The goal is to avoid hospitalization in the disease management model. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The disease management model focuses on providing education and instruction about the disease, its management, and self-monitoring. Long-term care and hospitalization frequency are not aspects of this approach to chronic care. Cognitive Level: Application Client Need: Health Promotion and Maintenance Client Need Sub: 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: 6. Describe essential elements and goals of coordinated primary care models such as the Transitional Care Model and the Patient-Centered Medical Home. MNL Learning Outcome: 6.8.1. Utilize the nursing process in care of client. Page Number: 39 Question 41 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: Interventions include an emphasis on early identification of and response to risks and symptoms to avoid adverse events. Rationale 2: Interventions include ongoing support and an emphasis on early identification of and response to risks and symptoms to avoid adverse events. Rationale 3: It is not the nurse’s responsibility to bill Medicare for the patient’s charges. Rationale 4: Interventions include development of an evidence-based plan of care. Rationale 5: It is not the nurse’s responsibility to review health insurance coverage plans. Global Rationale: Interventions include development of an evidence-based plan of care, ongoing support, and an emphasis on early identification of and response to risks and symptoms to avoid adverse events. It is not the nurse’s responsibility to perform billing duties or review health insurance coverage plans. Cognitive Level: Analysis LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Health Promotion and Maintenance Client Need Sub: 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: 6. Describe essential elements and goals of coordinated primary care models such as the Transitional Care Model and the Patient-Centered Medical Home. MNL Learning Outcome: 5.9.4. Utilize the nursing process in care of client. Page Number: 39 Question 42 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 4, 5 Rationale 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. Rationale 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. Rationale 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 health care, medication, food, or shelter. Rationale 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. Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
patterns of frequent acute health crises. Being hospitalized 9 months ago indicates an interruption in the pattern of frequent acute health crises. Global Rationale: 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, adhering to exercise, pain medication, and dietary plans, and infrequent hospitalizations indicate that the goals for transitional care have been met. The oldest daughter moving out of the house and a reduction in income could create crises for this patient. Cognitive Level: Analysis Client Need: Health Promotion and Maintenance Client Need Sub: 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: 6. Describe essential elements and goals of coordinated primary care models such as the Transitional Care Model and the Patient-Centered Medical Home. MNL Learning Outcome: 8.3.4. Utilize the nursing process in care of client. Page Number: 39 Question 43 Type: MCMA 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? Standard Text: Select all that apply. 1. Parish nursing 2. Homeless shelters 3. Adoption agencies 4. County health department 5. Ambulatory surgical center Correct Answer: 1, 2, 4, 5 Rationale 1: Community-based nursing care settings include parish nursing. Rationale 2: Community-based nursing care settings include homeless shelters. Rationale 3: Community-based nursing care settings do not include adoption agencies. Rationale 4: Community-based nursing care settings include county health departments. Rationale 5: Community-based nursing care settings include ambulatory surgical centers.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Community-based nursing care settings include parish nursing, homeless shelters, county health departments, and ambulatory surgical centers. Adoption agencies are not considered community-based nursing care settings. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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: 7. Describe services, settings, and essential components of community-based care and home healthcare. MNL Learning Outcome: Page Number: 40 Question 44 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 4 Rationale 1: Assessment in a rehabilitation facility includes functional health level and self-care abilities. Rationale 2: There is no expectation that the patient will provide all self-care. Rationale 3: Rehabilitation promotes reintegration into the patient’s family and community through a team approach. Rationale 4: Many different aspects of the patient’s life are addressed in the plan of care, including interpersonal relationships and family support. Rationale 5: Patients who receive care in a rehabilitation facility are not transferred to a long-term care facility. Global Rationale: Assessment in a rehabilitation facility includes functional health level and self-care abilities. Rehabilitation promotes reintegration into the patient’s family and community through a team approach. Many different aspects of the patient’s life are addressed in the plan of care, including interpersonal relationships and LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
family support. There is no expectation that the patient will provide all self-care. Patients who receive care in a rehabilitation facility are not transferred to a long-term care facility. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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: Knowledge and Science; Knowledge; Integration of knowledge from nursing and other disciplines Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe services, settings, and essential components of community-based care and home healthcare. MNL Learning Outcome: 8.3.4. Utilize the nursing process in care of client. Page Number: 40 Question 45 Type: MCMA 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? Standard Text: 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 upper-extremity mobility. Correct Answer: 1, 2, 5 Rationale 1: To receive healthcare coverage for home care, the patient must need intermittent skilled nursing care. Rationale 2: To receive healthcare coverage for home care, the patient must use an agency that is Medicare certified. Rationale 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. Rationale 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. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: To receive healthcare coverage for home care, the patient must need intermittent skilled nursing care, use an agency that is Medicare certified, and be homebound. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; health care systems Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Describe services, settings, and essential components of community-based care and home healthcare. MNL Learning Outcome: 11.3.4. Utilize the nursing process in care of client. Page Number: 41 Question 46 Type: MCSA The primary caregiver for a patient with stage 3 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. Correct Answer: 2 Rationale 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. Rationale 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. Rationale 3: There is no medical reason for the patient to be admitted to an inpatient facility. Rationale 4: The caregiver will not be able to drive and safely care for the patient at the same time. Global Rationale: 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. 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. There is no medical reason for the patient to be admitted to an inpatient facility. The caregiver will not be able to drive and safely care for the patient at the same time. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Application Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.6. Describe strategies to empower patients or families in all aspects of the health care 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: 7. Describe services, settings, and essential components of community-based care and home healthcare. MNL Learning Outcome: 7.8.4. Utilize the nursing process in care of client. Page Number: 42 Question 47 Type: MCMA The nurse is visiting the home of a patient recovering from an acute gastrointestinal bleed. Which actions should the nurse take to limit distractions during this home visit? Standard Text: 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 Correct Answer: 4, 5 Rationale 1: Establishing short- and long-term goals is setting priorities with the patient. Rationale 2: Explaining the primary goal of home care is setting goals and priorities. Rationale 3: Exploring the patient’s and family’s expectation of home care is setting goals and priorities. Rationale 4: Asking to turn off the television is limiting a distraction. Rationale 5: Asking to conduct the visit in a room away from children and pets is limiting a distraction. Global Rationale: Asking to turn off the television and conducting the visit in a room away from children and pets are ways to limit distractions. Establishing short- and long-term goals, explaining the primary goal of home care, and exploring the patient’s and family’s expectations of home care are setting goals and priorities. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.6. Describe strategies to empower patients or families in all aspects of the health care process LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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: 8. Discuss nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 11.3.4. Utilize the nursing process in care of client. Page Number: 43 Question 48 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 3, 5 Rationale 1: A water temperature of 150°F is too high. This could burn the patient. Rationale 2: Grab bars need to be within the bathtub or shower area in addition to near the commode. Rationale 3: Nonstick rugs should be used. Scatter rugs should be avoided or removed. Rationale 4: Smoke detectors are not routinely mounted near bathrooms. Rationale 5: Electrical outlets should not be near areas of water. Global Rationale: A water temperature of 150°F is too high. This could burn the patient. Grab bars need to be within the bathtub or shower area in addition to near the commode. Nonstick rugs should be used. Scatter rugs should be avoided or removed. Electrical outlets should not be near areas of water. Smoke detectors are not routinely mounted near bathrooms. Cognitive Level: Analysis Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the health care team AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety; Practice; Communicate potential risk factors and actual errors Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Discuss nursing interventions to deliver safe, effective, and competent care to patients in their homes. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 42 Question 49 Type: MCSA 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. Correct Answer: 4 Rationale 1: Used needles and syringes should not be placed in a plastic bag. They could puncture the bag and cause someone harm. Rationale 2: Doing nothing would be considered negligence on the part of the nurse. Rationale 3: The nurse is not responsible for disposing of a patient’s used needles and syringes. Rationale 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. Global Rationale: 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. Used needles and syringes should not be placed in a plastic bag. They could puncture the bag and cause someone harm. Doing nothing would be considered negligence on the part of the nurse. The nurse is not responsible for disposing of a patient’s used needles and syringes. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the health care team AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety; Practice; Communicate potential risk factors and actual errors Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 10.5.4. Overview of medical-surgical nursing. Page Number: 42-43 Question 50 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 3 Rationale 1: Placing the box of gloves next to the sink in the bathroom might not be convenient enough to encourage consistent use. Rationale 2: Hand washing should occur before and after wound care. Rationale 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. Rationale 4: Touching the edges of the soiled dressing will not prevent the spread of infection. Global Rationale: 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. Placing the box of gloves next to the sink in the bathroom might not be convenient enough to encourage consistent use. Hand washing should occur before and after wound care. Touching the edges of the soiled dressing will not prevent the spread of infection. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the health care team AACN Essentials Competencies: II.7. Promote factors that create a culture of safety and caring NLN Competencies: Quality and Safety; Practice; Communicate potential risk factors and actual errors Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Discuss nursing interventions to deliver safe, effective, and competent care to patients in their homes. MNL Learning Outcome: 4.1.4. Overview of medical-surgical nursing. Page Number: 43
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff, Medical-Surgical Nursing 6th Edition Test Bank Chapter 4 Question 1 Type: MCSA A patient tells the nurse that he must be having minor surgery 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.” Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not agree with the patient about outpatient surgery being minor. Rationale 3: The nurse does not know if the patient needs to be admitted to the hospital. Rationale 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. Global Rationale: 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. The nurse should not agree with the patient about outpatient surgery being minor. The nurse does not know if the patient needs to be admitted to the hospital. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 50
Question 2 Type: MCSA A patient scheduled for outpatient surgery asks the nurse why he will not be admitted to the hospital for the surgery. 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 Correct Answer: 1 Rationale 1: Advantages to outpatient surgery include a reduced risk of healthcare-associated infections. Rationale 2: The patient may or may not have home care for postoperative care in the home. Rationale 3: There is no evidence to suggest that patients who have outpatient surgery use fewer postoperative medications. Rationale 4: Saying that staffing on the surgical care areas is inadequate would be inappropriate. Global Rationale: Advantages to outpatient surgery include a reduced risk of healthcare-associated infections. The patient may or may not have home care for postoperative care in the home. There is no evidence to suggest that patients who have outpatient surgery use fewer postoperative medications. Saying that staffing on the surgical care areas is inadequate would be inappropriate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Communicate information effectively; listen openly and cooperatively Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 50
Question 3 Type: MCMA 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? Standard Text: 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 Correct Answer: 1,2,3,4 Rationale 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. Rationale 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. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Global Rationale 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. The patient’s expressing readiness to go home is not a criterion that would make him or her eligible for discharge after outpatient surgery. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 51
Question 4 Type: MCSA 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. Correct Answer: 1 Rationale 1: The major differences between inpatient and outpatient care lie in the degree of teaching and emotional support that are necessary for outpatient surgical patients and their families. The degree of teaching that LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
is necessary for outpatient surgical patients and their families is greater than for postoperative patients who recover as inpatients. Rationale 2: The nurse may or may not need to measure the patient’s intake and output. Rationale 3: The nurse will assess all surgical patients’ vital signs. Rationale 4: The nurse should ensure the patient’s pain is controlled and not limit pain medication. Global Rationale: The major differences between inpatient and outpatient care lie in the degree of teaching and emotional support that are necessary for outpatient surgical patients and their families. The degree of teaching that is necessary for outpatient surgical patients and their families is greater than for postoperative patients who recover as inpatients. The nurse may or may not need to measure the patient’s intake and output. The nurse will assess all surgical patients’ vital signs. The nurse should ensure the patient’s pain is controlled and not limit pain medication. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 51
Question 5 Type: MCSA The nurse is providing care to a patient during the preoperative phase of surgery. Which of the following interventions would be appropriate for the nurse to provide during this time? 1. assisting with bathing 2. patient safety 3. assessing level of consciousness 4. monitoring intake and output Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: During the preoperative phase of surgical care, the nurse will assist the patient physically become ready for the surgery. This may include assisting with bathing. Rationale 2: Patient safety is an intervention for the nurse during the intraoperative phase of surgical care. Rationale 3: Assessing level of consciousness is an intervention for the postoperative phase of surgical care. Rationale 4: Monitoring intake and output is an intervention for the postoperative phase of surgical care. Global Rationale: During the preoperative phase of surgical care, the nurse will assist the patient physically become ready for the surgery. This may include assisting with bathing. Patient safety is an intervention for the nurse during the intraoperative phase of surgical care. Assessing level of consciousness and monitoring intake and output are interventions for the postoperative phase of surgical care. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: Page Number: 69
Question 6 Type: MCSA A patient was instructed on exercises to perform as part of preoperative teaching. While recovering from surgery, the patient experiences a deep vein thrombosis (DVT). Which preoperative exercise should the nurse identify as not having been effective for this patient? 1. leg exercises 2. deep breathing and coughing 3. use of incentive spirometry 4. splinting when coughing Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: The preoperative patient is taught leg exercises in order to reduce the onset of the complication deep vein thrombosis. Rationale 2: Deep breathing and coughing are helpful to prevent complications of pneumonia and atelectasis. Rationale 3: Use of incentive spirometry is helpful to prevent complications of pneumonia and atelectasis. Rationale 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. Global Rationale: The preoperative patient is taught leg exercises in order to reduce the onset of the complication deep vein thrombosis (DVT). In this case, the leg exercises were ineffective and did not prevent DVT from occurring. Deep breathing and coughing and use of incentive spirometry are helpful to prevent complications of pneumonia and atelectasis. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: 6.3.1. Explain the incidence, risk factors, and pathophysiology for arterial and venous occlusive diseases. Page Number: 67
Question 7 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: The nurse needs to check the patient’s medical record to ensure that all orders written before surgery have been reordered after surgery, since the patient’s condition has changed. Rationale 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. Rationale 3: Orienting the patient to person, place, and time, is an activity of the PACU nurse. Rationale 4: Assessing the patient’s mental status is an activity of the PACU nurse. Global Rationale: The nurse needs to check the patient’s medical record to ensure that all orders written before surgery have been reordered after surgery, since the patient’s condition has changed. 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. Orienting the patient to person, place, and time, and assessing the patient’s mental status are activities of the PACU nurse. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: Page Number: 70
Question 8 Type: MCSA After providing a patient with 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not ask the patient to sign the consent form if the patient is under the influence of a sedative. Rationale 3: The nurse should not send the patient for surgery with an unsigned consent form. Rationale 4: The nurse should not phone the operating room suite to notify the nurse that the patient has not signed the consent form. Global Rationale: 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. The nurse should not ask the patient to sign the consent form if the patient is under the influence of a sedative. The nurse should not send the patient for surgery with an unsigned consent form. The nurse should not phone the operating room suite to notify the nurse that the patient has not signed the consent form. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 and Safety; Knowledge; Factors that contribute to a systemwide safety culture; the importance of reporting hazards and adverse events; the "just culture" approach to system improvement Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: Page Number: 51
Question 9 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: An increase in hemoglobin and hematocrit levels would indicate dehydration. Rationale 2: An alteration in glucose level could indicate impaired glucose metabolism or inadequate glucose level. Rationale 3: An alteration in white blood cell count could indicate an infection or immune deficiencies. Rationale 4: An alteration in platelet count could indicate a malignancy or clotting deficiency disorder. Global Rationale: An increase in hemoglobin and hematocrit levels would indicate dehydration. An alteration in glucose level could indicate impaired glucose metabolism or inadequate glucose level. An alteration in white blood cell count could indicate an infection or immune deficiencies. An alteration in platelet count could indicate a malignancy or clotting deficiency disorder. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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; Read and interpret data Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Interpret the significance of data used in the perioperative period to determine the patient’s health status and risk profile. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 57
Question 10 Type: MCSA 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 Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: The white blood cell count would provide information regarding an infection or immune deficiency. Rationale 3: The serum creatinine level provides information about the patient’s renal status. Rationale 4: The blood urea nitrogen level also provides information about the patient’s renal status. Global Rationale: 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. White blood cell count would provide information regarding an infection or immune deficiency. The serum creatinine and blood urea nitrogen levels provide information about the patient’s renal status. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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; Read and interpret data Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Interpret the significance of data used in the perioperative period to determine the patient’s health status and risk profile. MNL Learning Outcome: 5.9.2. Differentiate the manifestations and diagnostic tests of chronic obstructive pulmonary disease. Page Number: 57
Question 11 Type: MCSA 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. Correct Answer: 1 Rationale 1: An electrocardiogram (ECG) is ordered routinely for patients undergoing general anesthesia when they are over 40 years of age or have cardiovascular disease. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The electrocardiogram might detect preexisting cardiac disease but will not diagnose disease. Rationale 3: The electrocardiogram will not validate laboratory values. Rationale 4: The electrocardiogram is not used to predict the success of surgical procedures. Global Rationale: An electrocardiogram (ECG) is ordered routinely for patients undergoing general anesthesia when they are over 40 years of age or have cardiovascular disease. The electrocardiogram might detect preexisting cardiac disease but will not diagnose disease. The electrocardiogram will not validate laboratory values and is not used to predict the success of surgical procedures. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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; Read and interpret data Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Interpret the significance of data used in the perioperative period to determine the patient’s health status and risk profile. MNL Learning Outcome: 6.9.4. Compare the steps when analyzing a client’s cardiac rhythm. Page Number: 57
Question 12 Type: MCSA 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 Correct Answer: 1 Rationale 1: Older adults are susceptible to renal insufficiency, which puts them at risk for accumulation of metabolic by-products and medications dependent on renal clearance. Medication dosages will need to be adjusted for the older patient with a low glomerular filtration rate. Rationale 2: The glomerular filtration rate will not impact the patient’s postoperative activity level. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: The glomerular filtration rate will not impact the amount of intraoperative bleeding. Rationale 4: The glomerular filtration rate will not impact the patient’s oxygenation status. Global Rationale: Older adults are susceptible to renal insufficiency, which puts them at risk for accumulation of metabolic by-products and medications dependent on renal clearance. Medication dosages will need to be adjusted for the older patient with a low glomerular filtration rate. The glomerular filtration rate will not impact the patient’s postoperative activity level, amount of intraoperative blooding, or oxygenation status. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Knowledge; Read and interpret data; Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Interpret the significance of data used in the perioperative period to determine the patient’s health status and risk profile. MNL Learning Outcome: 12.3.3. Examine the diagnosis and treatment of kidney disorders. Page Number: 57-58
Question 13 Type: MCSA 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 Correct Answer: 1 Rationale 1: Antibiotics are given preoperatively to orthopedic patients to prevent postoperative infections. Rationale 2: Antacids increase the gastric pH and reduce the volume of gastric fluid. Rationale 3: Antiemetics enhance gastric emptying.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Anticholinergics reduce oral and respiratory secretions to decrease the risk of aspiration and vomiting. Global Rationale: Antibiotics are given preoperatively to orthopedic patients to prevent postoperative infections. Antacids increase the gastric pH and reduce the volume of gastric fluid. Antiemetics enhance gastric emptying. Anticholinergics reduce oral and respiratory secretions to decrease the risk of aspiration and vomiting. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: 8.3.3. Examine the diagnosis and treatment of degenerative disorders. Page Number: 58
Question 14 Type: MCSA 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 Correct Answer: 1 Rationale 1: For the patient who received lorazepam (Ativan), the nurse should monitor for respiratory depression, hypotension, lack of coordination, and drowsiness. Rationale 2: Nausea and vomiting is not associated with the use of lorazepam (Ativan). Rationale 3: Confusion is not associated with the use of lorazepam (Ativan). Rationale 4: Rash is not associated with the use of lorazepam (Ativan).
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: For the patient who received lorazepam (Ativan), the nurse should monitor for respiratory depression, hypotension, lack of coordination, and drowsiness. Nausea and vomiting, confusion, and rash are not associated with the use of lorazepam (Ativan). Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: 5.14.4. Utilize the nursing process in care of client. Page Number: 58
Question 15 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: The patient may or may not need artificial ventilations at this time. Rationale 3: The nurse should have been measuring the patient’s oxygen saturation throughout the procedure. Rationale 4: The patient is having difficulty maintaining an airway so applying oxygen via face mask may not be appropriate. Global Rationale: 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. The patient may or may not need artificial ventilations at this time. The nurse should have been measuring the patient’s oxygen saturation throughout the procedure. The patient is having difficulty maintaining an airway so applying oxygen via face mask may not be appropriate. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: 5.14.4. Utilize the nursing process in care of client. Page Number: 60
Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. 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. The nurse could help the patient into a more comfortable position and 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: Page Number: 60
Question 17 Type: MCSA 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. Correct Answer: 1 Rationale 1: The older patient may need extra blankets for warmth. This is what the nurse should do to ensure for the patient’s comfort. Rationale 2: The patient should be carefully turned and repositioned frequently to prevent the onset of pressure ulcers. Rationale 3: The nurse should speak in a low tone and not loudly. Rationale 4: The older patient needs an adequate fluid intake and may not need to have fluids limited. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The older patient may need extra blankets for warmth. This is what the nurse should do to ensure for the patient’s comfort. The patient should be carefully turned and repositioned frequently to prevent the onset of pressure ulcers. The nurse should speak in a low tone and not loudly. The older patient needs an adequate fluid intake and may not need to have fluids limited. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: Page Number: 56
Question 18 Type: MCSA When caring for an older patient having surgery, the nurse avoids shaving the patient. Which body system is the nurse supporting by using this intervention? 1. integumentary 2. sensory-perceptual 3. respiratory 4. cardiovascular Correct Answer: 1 Rationale 1: Avoiding shaving the older patient is one intervention to support the patient’s integumentary status. Rationale 2: Speaking in low tones and using adequate room lighting would support the patient’s sensoryperceptual status. Rationale 3: Teaching deep breathing and coughing and monitoring lung sounds would support the patient’s respiratory status. Rationale 4: Monitoring peripheral pulses and edema would support the patient’s cardiovascular status. Global Rationale: Avoiding shaving the older patient is one intervention to support the patient’s integumentary status. Speaking in low tones and using adequate room lighting would support the patient’s sensory-perceptual LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
status. Teaching deep breathing and coughing and monitoring lung sounds would support the patient’s respiratory status. Monitoring peripheral pulses and edema would support the patient’s cardiovascular status. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 74
Question 19 Type: MCSA An older patient, recovering from surgery, is prescribed a soft diet. The nurse realizes that this diet supports which age-related change? 1. decline in gastric motility 2. reduced intestinal absorption 3. lactose intolerance 4. gall bladder insufficiency Correct Answer: 1 Rationale 1: A soft diet helps with this change in the older adult. Rationale 2: Reduced intestinal absorption is not a gastrointestinal age-related change. Rationale 3: Lactose intolerance can occur at many ages. Rationale 4: Gall bladder insufficiency is not a gastrointestinal age-related change. Global Rationale: A soft diet helps with this change in the older adult. Reduced intestinal absorption is not a gastrointestinal age-related change. Lactose intolerance can occur at many ages. Gall bladder insufficiency is not a gastrointestinal age-related change. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 11.8.1. Explain the incidence and pathophysiology for disorders of intestinal motility. Page Number: 74 Question 20 Type: MCSA 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. Correct Answer: 1 Rationale 1: To support the older patient’s cognitive-psychosocial status, the nurse should provide ample time for teaching and learning. Rationale 2: The nurse should not treat the older patient as a child by setting limits. Rationale 3: The nurse should not treat the older patient as a child by stating that all care decisions will be made by the physician. Rationale 4: The nurse should not treat the older patient as a child by reminding that the call bell is for emergencies only. Global Rationale: To support the older patient’s cognitive-psychosocial status, the nurse should provide ample time for teaching and learning. The nurse should not treat the older patient as a child by setting limits, by stating that all care decisions will be made by the physician, or by reminding that the call bell is for emergencies only. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: Page Number: 74
Question 21 Type: MCSA A patient recovering from surgery reports a pain level of 6 on a 0–10 pain scale but refuses additional pain medication since he does not want to “become addicted.” The nurse’s response should focus on which concept? 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. Correct Answer: 1 Rationale 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. Rationale 2: The patient who already has an addiction problem most likely would be requesting more medication, not refusing it. Rationale 3: The patient is verbalizing pain, so administration of a placebo is unethical, against patient rights for pain management, and should not be administered. Rationale 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. Global Rationale: 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. The patient who already has an addiction problem most likely would be requesting more medication, not refusing it. The patient is verbalizing pain, so administration of a placebo is unethical, against patient rights for pain management, and should not be administered. It is within the scope of the nurse to review LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe principles of pain management specific to acute postoperative pain control. MNL Learning Outcome: Page Number: 61
Question 22 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: NSAIDs do not usually affect blood pressure. Rationale 3: NSAIDs do not usually affect respiratory rate. Rationale 4: NSAIDs do not usually affect heart rate. Global Rationale: 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. NSAIDs do not usually affect blood pressure, respiratory rate, or heart rate. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe principles of pain management specific to acute postoperative pain control. MNL Learning Outcome: 12.3.1. Explain the incidence, causes, risk factors, and pathophysiology of kidney disorders. Page Number: 61
Question 23 Type: MCSA An older surgical patient is having an epidural catheter inserted for pain control. What does 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 Correct Answer: 1 Rationale 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. Rationale 2: Patient-controlled epidural analgesia does not cause faster wound healing in the older patient. Rationale 3: Patient-controlled epidural analgesia does not cause earlier ambulation in the older patient. Rationale 4: Patient-controlled epidural analgesia does not cause improved appetite in the older patient. Global Rationale: 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. Patient-controlled epidural analgesia does not cause faster wound healing, earlier ambulation, or improved appetite in the older patient. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe principles of pain management specific to acute postoperative pain control. MNL Learning Outcome: Page Number: 60
Question 24 Type: MCSA A patient says that his condition must be getting worse since he was receiving 10 mg morphine sulfate through the IV for pain but now is prescribed Demerol 50 mg by mouth at home. How should the nurse respond to this patient? 1. “Oral doses need to be higher than those given through an IV. It does not mean your condition is worse.” 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.” Correct Answer: 1 Rationale 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. Rationale 2: The physician is not making sure the patient has no pain at home. Rationale 3: The nurse does not need to get the physician to explain the patient’s condition. Rationale 4: Not all patients have more pain when they are discharged after surgery. Global Rationale: 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. The physician is not making sure the patient has no pain at home. The nurse does not need to get the physician to explain the patient’s condition. Not all patients have more pain when they are discharged after surgery. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe principles of pain management specific to acute postoperative pain control. MNL Learning Outcome: Page Number: 61
Question 25 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The preoperative phase is prior to surgery. Rationale 3: The intraoperative phase occurs during the surgery. Rationale 4: Restorative is not a phase of the surgical experience. Global Rationale: The postoperative phase begins when the patient is admitted to the recovery room and ends with the patient’s recovery from the surgical intervention. The preoperative phase is prior to surgery. The intraoperative phase occurs during the surgery. Restorative is not a phase of the surgical experience. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: Page Number: 61
Question 26 Type: MCSA A patient is signing a surgical consent. Afterwards, the nurse also signs the form. What is the meaning of the nurse’s signature? 1. It means the patient was alert and aware of what was being signed. 2. It means the patient understood the procedure as described by the nurse. 3. It means the surgeon was too busy to wait for the patient to sign the form. 4. It means there is a likelihood of a successful outcome. Correct Answer: 1 Rationale 1: The nurse also signs the form to indicate that the correct person is signing the form and that the patient was alert and aware of what was being signed. Rationale 2: Providing a description of the surgical procedure is not the responsibility of the nurse. Obtaining the consent form is a nursing function. Rationale 3: The physician’s schedule is not a factor. Rationale 4: Success of the outcome is not dependent upon the completion of the consent form. Global Rationale: The nurse also signs the form to indicate that the correct person is signing the form and that the patient was alert and aware of what was being signed. Providing a description of the surgical procedure is not the responsibility of the nurse. It is the responsibility of the physician. Obtaining the consent form is a nursing function. The physician’s schedule is not a factor. Success of the outcome is not dependent upon the completion of the consent form. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Knowledge; principles of informed consent, confidentiality, patient self-determination Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 51
Question 27 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: No information is provided to indicate the use of herbal supplements. Rationale 3: Despite delayed wound healing, there is no information to support the increased risk for wound dehiscence. Rationale 4: Cognition remains stable in older adults, but information processing slows. Global Rationale: 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. No information is provided to indicate the use of herbal supplements. Despite delayed wound healing, there is no information to support the increased risk for wound dehiscence. Cognition remains stable in older adults, but information processing slows. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: Page Number: 74
Question 28 Type: MCSA An older patient is completing preoperative diagnostic testing. The nurse notes that the patient’s carbon dioxide level is elevated. 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 Correct Answer: 1 Rationale 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. Rationale 2: A review of the potassium level is not the most beneficial to this patient at this time. Rationale 3: A review of the sodium level is not the most beneficial to this patient at this time. Rationale 4: A review of the intake and output is not the most beneficial to this patient at this time. Global Rationale: 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. A review of the potassium, sodium levels, and intake and output are not the most beneficial to this patient at this time. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.8. 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: Planning Learning Outcome: 3. Interpret the significance of data used in the perioperative period to determine the patient’s health status and risk profile. MNL Learning Outcome: 0.1.2. Correlate the information related to specific serum laboratory studies to client care. Page Number: 57
Question 29 Type: MCSA An older postoperative patient 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 Correct Answer: 1 Rationale 1: Antiemetics, such as Metoclopramide (Reglan) and Droperidol (Inapsine), can have tranquilizing effects as well as cause an extrapyramidal reaction. The patient would demonstrate involuntary movements, muscle tone changes, and abnormal posturing. Rationale 2: Elderly patients may also experience drowsiness, which reduces orientation, after being given antiemetics. Rationale 3: A dry mouth may be experienced as a result of having been or currently being unable to have oral intake. Rationale 4: Breakthrough vomiting is not an indication of an adverse reaction. Global Rationale: Antiemetics, such as metoclopramide (Reglan) and droperidol (Inapsine), can have tranquilizing effects as well as cause an extrapyramidal reaction. The patient would demonstrate involuntary movements, muscle tone changes, and abnormal posturing. Elderly patients may also experience drowsiness, which reduces orientation, after being given antiemetics. A dry mouth may be experienced as a result of having been or currently being unable to have oral intake. Breakthrough vomiting is not an indication of an adverse reaction. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Evaluation Learning Outcome: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: Page Number: 58
Question 30 Type: MCSA The nurse is assisting a postoperative patient in using an incentive spirometer. Which postoperative complications is this nurse attempting to avoid? 1. atelectasis 2. deep vein thrombosis 3. hemorrhage 4. pulmonary embolism Correct Answer: 1 Rationale 1: Promoting lung expansion and systemic oxygenation of tissues is a goal in preventing atelectasis. Nursing care includes assisting with incentive spirometry. Rationale 2: Deep vein thrombosis is not related to incentive spirometer use. Rationale 3: Hemorrhage is not related to incentive spirometer use. Rationale 4: Pulmonary embolism is not related to incentive spirometer use. Global Rationale: Promoting lung expansion and systemic oxygenation of tissues is a goal in preventing atelectasis. Nursing care includes assisting with incentive spirometry. Deep vein thrombosis, hemorrhage, and pulmonary embolism are not related to incentive spirometer use. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 and Safety; Knowledge; Factors that contribute to a systemwide safety culture; the importance of reporting hazards and adverse events; the "just culture" approach to system improvement Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: 5.3.1. Explain the risk factors and pathophysiology of infectious lung diseases. Page Number: 73
Question 31 Type: MCSA A patient’s postoperative wound has sanguineous drainage with a thick, reddish appearance. The nurse realizes this patient’s wound is in which phase of healing? 1. Inflammatory 2. Proliferative 3. Stationary 4. Remodeling Correct Answer: 1 Rationale 1: The inflammatory phase begins with the surgical incision. Sanguineous drainage contains both serum and red blood cells and has a thick, reddish appearance. Rationale 2: The proliferative phase begins within 2 to 3 days after surgery. Rationale 3: Stationary is not a phase of wound healing. Rationale 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. Global Rationale: The inflammatory phase begins with the surgical incision. Sanguineous drainage contains both serum and red blood cells and has a thick, reddish appearance. The proliferative phase begins within 2 to 3 days after surgery. Stationary is not a phase of wound healing. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.8. 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; Function competently within one's own scope of practice as leader or member of the health care team Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 71
Question 32 Type: MCSA A patient who is recovering from abdominal surgery has a Penrose drain. What should the nurse include in the care of this patient? 1. Make sure there is a safety pin on the end of the drain. 2. Empty the drain every 30 minutes. 3. Clean the wound with normal saline every two hours. 4. Remove the drain four hours postoperatively. Correct Answer: 1 Rationale 1: Penrose drains need a safety pin at the exposed end to prevent the drain from slipping down into the wound. Rationale 2: Unless full or assessing for a potential problem, there is no need to empty the drain until the end of the shift. Rationale 3: There is no need to clean the wound with saline. Rationale 4: Removal of the drain requires a physician’s order. Global Rationale: Penrose drains need a safety pin at the exposed end to prevent the drain from slipping down into the wound. Unless full or assessing for a potential problem, there is no need to empty the drain until the end of the shift. There is no need to clean the wound with saline. Removal of the drain requires a physician’s order. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Identify the three phases of perioperative care. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 71
Question 33 Type: MCSA During the assessment of a postoperative patient’s bowel sounds, the nurse auscultates absent sounds over all four abdominal quadrants. The nurse realizes this finding could indicate what health problem? 1. paralytic ileus 2. normal bowel function 3. the onset of flatus 4. the onset of stool Correct Answer: 1 Rationale 1: A distended abdomen with absent bowel sounds may indicate paralytic ileus. Rationale 2: Normal bowel sounds are low in pitch. Rationale 3: The onset or presence of flatus is accompanied by bowel sounds. Rationale 4: The onset of stool is accompanied by bowel sounds. Global Rationale: A distended abdomen with absent bowel sounds may indicate paralytic ileus. Normal bowel sounds are low in pitch. The onset or presence of flatus and stool is accompanied bowel sounds. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: 11.3.2. Differentiate the manifestations of stomach and duodenum disorders. Page Number: 74 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 34 Type: MCSA 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 Correct Answer: 1 Rationale 1: Surgical procedures are classified according to purpose, risk factor, and urgency. Cataract extraction would be considered a minor elective surgery. Minor procedures carry minimal risk and minimal physical assault. Rationale 2: A minor diagnostic surgery is used to determine or confirm a condition. Rationale 3: Major constructive procedures require extensive physical assault and/or serious risk. Constructive procedures are used to build tissue/organs which are absent. Rationale 4: Major elective procedures are suggested to the patient by the physician but there is little risk if they are not performed. Global Rationale: Surgical procedures are classified according to purpose, risk factor, and urgency. Cataract extraction would be considered a minor elective surgery. Minor procedures carry minimal risk and minimal physical assault. A minor diagnostic surgery is used to determine or confirm a condition. Major constructive procedures require extensive physical assault and/or serious risk. Constructive procedures are used to build tissue/organs which are absent. Major elective procedures are suggested to the patient by the physician but there is little risk if they are not performed. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Planning Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: 9.1.3. Examine the diagnosis and treatment of age-related eye disorders. Page Number: 50 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 35 Type: MCSA A patient who is being admitted for surgery asks the nurse why information is being collected about the patient’s 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.” Correct Answer: 1 Rationale 1: The use of herbal supplements must be documented prior to surgery. It is possible for these elements to interact with anesthetic agents. Rationale 2: Herbal remedies have not been shown to render analgesics ineffective. Rationale 3: Stating that the physician is in charge of medications does not adequately respond to the patient’s inquiry. Rationale 4: Stating that there is no need to take these prescriptions does not adequately respond to the patient’s inquiry. Global Rationale: The use of herbal supplements must be documented prior to surgery. It is possible for these elements to interact with anesthetic agents. Herbal remedies have not been shown to render analgesics ineffective. Stating that the physician is in charge of medications and that there is no need to take these prescriptions does not adequately respond to the patient’s inquiry. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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 health care NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: Page Number: 53 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 36 Type: MCMA 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? Standard Text: 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.” Correct Answer: 1, 2, 3 Rationale 1: The use of opioid analgesics during the postoperative period is rarely associated with physical dependency concerns. Rationale 2: The use of opioid analgesics during the postoperative period is rarely associated with psychological dependency concerns. Rationale 3: The pain management needs of patients will vary and should be managed individually. Rationale 4: Screening is not routinely recommended for surgical patients. Rationale 5: This does not address the patient’s need for pain control or the patient’s concern over addiction from postoperative opioid analgesics. Global Rationale: The use of opioid analgesics during the postoperative period is rarely associated with physical or psychological dependency concerns. The pain management needs of patients will vary and should be managed individually. Screening is not routinely recommended for surgical patients. Offering to turn on the TV to distract the patient does not address the patient’s need for pain control or the patient’s concern over addiction from postoperative opioid analgesics. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 6. Describe principles of pain management specific to acute postoperative pain control. MNL Learning Outcome: Page Number: 61
Question 37 Type: MCSA The patient who is preparing for surgery asks the nurse to keep his glasses and hearing aid in place until he is under 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.” Correct Answer: 1 Rationale 1: Although communication will be enhanced if the patient can keep glasses and hearing aids for as long as possible, the nurse will need to check with the surgical department first before granting the patient’s wish. Rationale 2: As a patient advocate, the nurse is responsible for making an inquiry. Rationale 3: The nurse does not have the authority to make decisions on behalf of the surgical department. Rationale 4: The nurse should not give information that may be inaccurate. Global Rationale: Although communication will be enhanced if the patient can keep glasses and hearing aids for as long as possible, the nurse will need to check with the surgical department first before granting the patient’s wish. As a patient advocate, the nurse is responsible for making an inquiry. The nurse does not have the authority to make decisions on behalf of the surgical department and should not give information that may be inaccurate. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Quality and Safety; Practice; 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. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 69
Question 38 Type: MCHS The nurse is assigned as the surgical scrub nurse for outpatient cases. Place an “X” on the picture that depicts how the nurse will dress for these cases.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: The surgical scrub nurse handles sutures, instruments, and other equipment immediately adjacent to the sterile field and therefore wears the sterile attire pictured on the right. The picture on the left depicts surgical attire that is worn by those not participating at the operating table. Global Rationale: Cognitive Level: Analyzing Client Need: Safe and Effective Care and Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.3. Value own role in preventing errors 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 and Safety; Practice; 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. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 63 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 39 Type: MCHS The patient is scheduled for a perineal surgery. Place an “X” on the position in which the nurse would place this patient for surgery.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: This position is called the lithotomy position and it is used for gynecologic, perineal, or rectal surgeries. The first position is the prone position, which is used for spinal surgeries and removal of hemorrhoids. The center position is the lateral chest position, which is used for some thoracic surgeries, as well as hip replacements. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care and Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.3. Value own role in preventing errors 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 and Safety; Practice; 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. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: Page Number: 65 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 40 Type: MCSA The nurse takes the form identified below to a patient’s room in preparation for an emergency surgical procedure. The patient states, “Doc said he would tell me all about the surgery when he gets here. Do you know what they are going to do?” What is the nurse’s best response?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. “Let’s wait on signing this until your physician has talked to you.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. “Let me go get a medical surgical textbook so I can use the pictures to explain the procedure.” 3. “I am not certain; let me call the nursing supervisor to explain it to you.” 4. “Go ahead and sign this so we will have that part done when the physician gets here.” Correct Answer: 1 Rationale 1: The form pictured is an informed consent document. It should not be signed until the procedure has been explained to the patient, and the explanation is the responsibility of the physician. Rationale 2: This nurse should not explain the procedure. Rationale 3: This nurse should not ask another nurse to do so. Rationale 4: The signing of this document must wait until the patient is educated about the procedure so that true “informed” consent can be given. Global Rationale: The form pictured is an informed consent document. It should not be signed until the procedure has been explained to the patient, and the explanation is the responsibility of the physician. This nurse should not explain the procedure or ask another nurse to do so. The signing of this document must wait until the patient is educated about the procedure so that true “informed” consent can be given. Cognitive Level: Applying Client Need: Safe and Effective Care and Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.C.3. Value own role in preventing errors 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 and Safety; Practice; 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: 2. Identify the three phases of perioperative care. MNL Learning Outcome: Page Number: 51
Question 41 Type: MCSA While completing item number 4 in the preoperative preparation section of the form provided below, the nurse notes that the patient depends on a hearing aid. What action should the nurse take?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Leave the device in the patient’s ear and notify the OR nurse of its presence. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Remove the device and place it in a denture cup in the patient’s room. 3. Remove the device and give it to the patient’s family member. 4. Place a piece of tape across the patient’s ear and the device. Correct Answer: 1 Rationale 1: The patient must be able to hear and understand instruction that will be part of the universal protocol to reduce surgical errors, so the nurse should leave the device in the patient’s ear and notify the OR nurse of its presence. Rationale 2: Removing the device and placing it in a denture cup in the room will make it unavailable to the patient in the OR. Rationale 3: Giving the device to the family will make it unavailable to the patient in the OR. Rationale 4: Taping the device into the ear might damage it or cause injury to the patient’s ear. Global Rationale: The patient must be able to hear and understand instruction that will be part of the universal protocol to reduce surgical errors, so the nurse should leave the device in the patient’s ear and notify the OR nurse of its presence. Removing the device and placing it in a denture cup in the room or giving it to the family will make it unavailable to the patient in the OR. Taping the device into the ear might damage it or cause injury to the patient’s ear. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in care 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 and Safety; Practice; 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: 2. Identify the three phases of perioperative care. MNL Learning Outcome: Page Number: 69
Question 42 Type: MCMA The nurse is changing the abdominal surgical dressing of an older patient who has developed pneumonia and a cough. Upon removing the dressing, the nurse notes the situation as pictured below. What should be the nurse’s intervention? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: Select all that apply. 1. Place saline moistened sterile dressing over the incision. 2. Notify the patient’s surgeon of the occurrence. 3. Don sterile gloves and insert the loop of bowel back into the abdomen. 4. Document the presence of a dehiscence in the medical record. 5. Replace the dressing and ask the oncoming shift to advise the physician about the situation when rounds are made. Correct Answer: 1, 2 Rationale 1: The tissue must be kept moist, so application of a sterile dressing that is moistened with sterile saline is appropriate. Rationale 2: The surgeon should be made aware of the situation immediately, as a return to the OR will probably be necessary. Rationale 3: The nurse should not attempt to put the loop of bowel back into the abdomen, as this might cause additional trauma. Rationale 4: Documentation is not a priority in this emergency situation. Rationale 5: The surgeon should be made aware of the situation immediately, as a return to the OR will probably be necessary, so having the next shift notify the surgeon is wrong. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: This situation depicts an evisceration, which is an emergency situation, not a dehiscence. Older patients may be at greater risk for this postoperative complication because of thinning of the skin and subcutaneous tissues. The tissue must be kept moist, so application of a sterile dressing that is moistened with sterile saline is appropriate. The surgeon should be made aware of the situation immediately, as a return to the OR will probably be necessary, so having the next shift notify the surgeon is wrong. The nurse should not attempt to put the loop of bowel back into the abdomen as this might cause additional trauma. Documentation is not a priority in this emergency situation. Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 72
Question 43 Type: MCSA The patient who had an emergency abdominal surgery looks at his incision on the first postoperative day and says, “I sure hope this doesn’t leave much of a scar. Is there some type of medicine or ointment I can put on it?” What should the nurse consider prior to responding to that comment?
1. This incision will heal by primary intention and will probably leave only a hairline scar. 2. This incision will fill in with granulation tissue and leave a moderately big scar despite any medication applied. 3. This incision was done in an emergent fashion but continuous application of steroid creams will prevent scarring. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. This incision will have to be reclosed later and will leave a large scar unless a topical antibiotic is used continuously. Correct Answer: 1 Rationale 1: This picture shows a clean, straight incision that was closed early, so it will probably leave a hairline scar. This is called healing by primary intention. Rationale 2: Healing by secondary intention is when the incision is left open and granulation begins. This leaves a large scar. Rationale 3: The fact that this was an emergency surgery should have nothing to do with the scarring potential if the incision is clean and closed immediately. Rationale 4: Healing by secondary intention occurs when the incision is left open and granulation begins. This leaves a large scar. Global Rationale: This picture shows a clean, straight incision that was closed early, so it will probably leave a hairline scar. This is called healing by primary intention. Healing by secondary intention is when the incision is left open and granulation begins. This leaves a large scar. The fact that this was an emergency surgery should have nothing to do with the scarring potential if the incision is clean and closed immediately. Healing by secondary intention is when the incision is left open and granulation begins. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 70
Question 44 Type: MCMA The nurse is changing the surgical dressing on an older patient’s abdomen and sees the item pictured in the diagram below. How should the nurse care for this device?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: Select all that apply. 1. Plan to replace the precut gauze as part of the dressing change. 2. Cleanse around the tube with the cleanser ordered or according to protocol. 3. Use the safety pin to secure the outermost bandage to the dressing. 4. Remove the tube, culture the wound, and cleanse it with saline gauze 5. Remove the safety pin Correct Answer: 1, 2 Rationale 1: The nurse cares for this device by cleansing around it per hospital protocol and replacing the precut gauze dressing as necessary. Rationale 2: The nurse cares for this device by cleansing around it per hospital protocol and replacing the precut gauze dressing as necessary. Rationale 3: The pin should not be used to secure the dressing as that would make it very easy to inadvertently pull the drain out when the dressings are removed to be changed.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The drain is there to passively remove drainage from the wound bed, and it should not be removed until there is a physician order to do so. A culture is necessary only if there are assessment findings that indicate possible infection. Rationale 5: The safety pin is in place to keep the drain from slipping back into the patient, so it should not be removed. Global Rationale: This is a Penrose drain. The nurse cares for this device by cleansing around it per hospital protocol and replacing the precut gauze dressing as necessary. The pin should not be used to secure the dressing as that would make it very easy to inadvertently pull the drain out when the dressings are removed to be changed. The drain is there to passively remove drainage from the wound bed and it should not be removed until there is a physician order to do so. A culture is necessary only if there are assessment findings that indicate possible infection. The safety pin is in place to keep the drain from slipping back into the patient, so it should not be removed. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 71
Question 45 Type: MCMA A patient is scheduled to have a hernia repair done today on an outpatient basis. The patient’s sibling angrily says, “When I had this done 20 years ago, they kept me in the hospital nearly a week. Why can’t my brother stay here where someone can take care of him?” What are appropriate responses by the nurse? Standard Text: Select all that apply. 1. “He will be at less risk of getting an infection at home.” 2. “He will probably be more comfortable in his own bed at home.” 3. “It is cheaper for the insurance company if he goes home today.” 4. “The government won’t let him stay.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
5. “If you ask the physician, the hospital will probably let him stay.” Correct Answer: 1, 2 Rationale 1: The best answers to this angry sibling focus on what is best for the patient, so replying about reduction of infection risk and comfort are the best choice. Rationale 2: The best answers to this angry sibling focus on what is best for the patient, so replying about reduction of infection risk and comfort are the best choice. Rationale 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. Rationale 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. Rationale 5: It is also not advisable to infer that the hospital has a decision to make in whether this patient stays or goes home. Global Rationale: The best answers to this angry sibling focus on what is best for the patient, so replying about reduction of infection risk and comfort are the best choice. 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. It is also not advisable to infer that the hospital has a decision to make in whether this patient stays or goes home. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 1. Compare the differences and similarities between outpatient and inpatient surgery. MNL Learning Outcome: 12.13.3. Examine the diagnosis and treatment of abdominal structural and obstructive disorders. Page Number: 50
Question 46 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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).” 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.” Correct Answer: 4 Rationale 1: Anticoagulant medications, including warfarin (Coumadin), should be discontinued prior to surgery to prevent excessive blood loss during surgery. Rationale 2: Herbs or nutritional supplements that impair clotting should be discontinued 2 weeks prior to surgery. Rationale 3: Antihypertensive medications will be analyzed by the healthcare provider on an individual basis. Rationale 4: Anticoagulant medications should be discontinued prior to surgery to prevent excessive blood loss during surgery. These include aspirin. Global Rationale: Anticoagulant medications, including warfarin (Coumadin) and aspirin, should be discontinued prior to surgery to prevent excessive blood loss during surgery. Herbs or nutritional supplements that impair clotting should be discontinued 2 weeks prior to surgery. Antihypertensive medications will be analyzed by the healthcare provider on an individual basis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 4. Explain nursing implications for medications prescribed for the surgical patient. MNL Learning Outcome: Page Number: 56
Question 47 Type: SEQ
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Standard Text: Click and drag the options below to move them up or down. Choice 1. Administer oxygen with a nonrebreather mask. Choice 2. Check IV access. Choice 3. Notify the anesthesia provider. Choice 4. Administer Dantrolene. Correct Answer: 1,2,3,4 Rationale 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. Rationale 2: The nurse should then be certain 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. Rationale 3: The nurse should then be certain 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. Rationale 4: Dantrolene is given IV, so a patent IV is essential. Global Rationale: 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. The nurse should then be certain 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. Dantrolene is given IV, so a patent IV is essential. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 4. Explain nursing implications for medications prescribed for the surgical patient.. MNL Learning Outcome: Page Number: 59 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 48 Type: SEQ The nurse is preparing to teach an older 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. Sit up straight in bed. Choice 2. Place your hands lightly on your abdomen. Choice 3. Breathe in deeply through your nose. Choice 4. Hold your breath for five seconds. Choice 5. Completely exhale through pursed lips. Correct Answer: 1,2,3,4,5 Rationale 1: The patient should be placed in high or semi-Fowler’s position. Rationale 2: The patient should be asked to place hands lightly on the abdomen. Rationale 3: The patient should be asked to take a deep breath in through the nose. Rationale 4: The patient should be asked to hold the breath to the count of five. Rationale 5: The patient should be asked to exhale completed through pursed lips. Global Rationale: The patient should be placed in high or semi-Fowler’s position, asked to place hands lightly on the abdomen, asked to take a deep breath in through the nose, asked to hold the breath to the count of five, asked to exhale completed through pursed lips, then encouraged to repeat the exercise five times consecutively. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 5.3.4. Utilize the nursing process in care of client. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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Question 49 Type: MCMA Which patient information is essential for the nurse to provide the physician who is preparing to administer conscious sedation to a patient? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: While all of this information leads to a greater understanding of the patient, that the patient snores is essential information at this time. Rationale 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. Rationale 3: That the patient wishes to be asleep for the procedure is not essential information. Rationale 4: That the patient’s father was hypertensive is not essential information at this time. Rationale 5: That the patient has a history of gout is not essential information at this time. Global Rationale: While all of this information leads to a greater understanding of the patient, the essential information is that the patient snores and that the patient is not NPO. The other information is not relevant at this time. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. Implement evidence-based nursing interventions as appropriate for managing the acute and chronic care of patients and promoting health across the lifespan LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice: conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 5.14.4. Utilize the nursing process in care of client. Page Number: 60
Question 50 Type: MCSA A patient being prepared for surgery has a history of chronic obstructive pulmonary disease. Which diagnostic test should the nurse expect to 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 Correct Answer: 1 Rationale 1: Pulmonary function studies often are performed with patients who have chronic obstructive pulmonary disease to determine the extent of respiratory dysfunction. Rationale 2: There is no reason for a CT scan of the brain to be completed. Rationale 3: There is no reason for a lumbar puncture to be completed. Rationale 4: There is no reason for an abdominal MRI to be completed. Global Rationale: Pulmonary function studies often are performed with patients who have chronic obstructive pulmonary disease to determine the extent of respiratory dysfunction. There is no reason for the patient to have a CT scan of the brain, lumbar puncture, or MRI of the abdomen. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 3. Interpret the significance of data used in the perioperative period to determine the patient’s health status and risk profile. MNL Learning Outcome: 5.9.2. Differentiate the manifestations and diagnostic tests of chronic obstructive pulmonary disease. Page Number: 57
Question 51 Type: MCMA A 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? Standard Text: 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. Correct Answer: 1, 3, 5 Rationale 1: Promote fluid intake as allowed, monitoring intake and output. Rationale 2: Turning onto the left side will not promote urinary elimination. Rationale 3: Assess for bladder distention if the patient has not voided within 7 to 8 hours after surgery. Rationale 4: Urinary catheterizations should be avoided to reduce the potential for urinary tract infections and urethral trauma. Rationale 5: Use a portable ultrasound scanner to determine the amount of urine in the bladder. Global Rationale: The nurse should promote fluid intake as allowed, monitoring intake and output. Assess for bladder distention if the patient has not voided within 7 to 8 hours after surgery. Use a portable ultrasound scanner to determine the amount of urine in the bladder. Turning onto the left side will not promote urinary elimination. Urinary catheterizations should be avoided to reduce the potential for urinary tract infections and urethral trauma. Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Identify variations in perioperative care for patients across the life span and with differing needs based on culture. MNL Learning Outcome: 12.1.3. Examine the diagnosis and treatment of urinary tract and bladder conditions. Page Number: 74
Question 52 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 4 Rationale 1: During the maintenance phase of anesthesia, the skin is prepared. Rationale 2: The anesthesiologist monitors the patient’s blood pressure, heart rate, and oxygen saturation level at this time. Rationale 3: During the maintenance phase of anesthesia, the surgery is performed. Rationale 4: During the maintenance phase of anesthesia, the patient is positioned. Rationale 5: The anesthesiologist monitors the patient’s blood pressure, heart rate, and oxygen saturation level at this time. Global Rationale: During the maintenance phase of anesthesia, the patient is positioned, the skin is prepared, and surgery is performed. The anesthesiologist monitors the patient’s blood pressure, heart rate, and oxygen saturation level at this time. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 7. Differentiate the care needed for patients receiving varying levels of anesthesia care. MNL Learning Outcome: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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Question 53 Type: MCMA 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? Standard Text: Select all that apply. 1. Spinal 2. Topical 3. Epidural 4. Nerve block 5. Local nerve infiltration Correct Answer: 3, 4 Rationale 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. Rationale 2: Topical anesthesia would not be an option for this case. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. 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. 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. Topical anesthesia would not be an option for this case. 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. Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care NLN Competencies: Relationship Centered Care; Practice: learn cooperatively, facilitate the learning of others Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Differentiate the care needed for patients receiving varying levels of anesthesia care. MNL Learning Outcome: 8.1.3. Distinguish the diagnosis and treatment of traumatic musculoskeletal injuries. Page Number: 60
Question 54 Type: MCMA The nurse determines that a patient recovering from spinal anesthesia is experiencing complications from the anesthesia. Which actions should the nurse expect to be provided to this patient? Standard Text: Select all that apply. 1. Caffeine 2. Analgesics 3. Intravenous fluids 4. Epidural blood patch 5. Vasoactive medication Correct Answer: 1, 2, 3, 4 Rationale 1: Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include caffeine. Rationale 2: Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include analgesics. Rationale 3: Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include hydration. Rationale 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. Rationale 5: Vasoactive medications are used if hypotension occurs. Global Rationale: Leakage of cerebrospinal fluid (CSF) into the epidural space can cause reduced CSF pressure and postoperative headaches. Treatment may include hydration, caffeine, analgesics, or administration of an epidural blood patch. Vasoactive medications are used if hypotension occurs. Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 7. Differentiate the care needed for patients receiving varying levels of anesthesia care. MNL Learning Outcome: 7.2.3. Examine the diagnosis and treatment of headaches. Page Number: 60
Question 55 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 4, 5 Rationale 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. Rationale 2: Atropine is not indicated in the treatment of this adverse effect of epidural anesthesia. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. Atropine is not indicated in the treatment of this adverse effect of epidural anesthesia. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 7. Differentiate the care needed for patients receiving varying levels of anesthesia care. MNL Learning Outcome: 6.1.3. Examine the treatment options for disorders of blood pressure regulation. Page Number: 60
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 5 Question 1 Type: MCSA The brother of a terminally ill patient states, “I’ll donate a million dollars to the hospital if they cure my brother.” The nurse realizes this statement indicates which phase of Kübler-Ross’s stages of loss? 1. bargaining 2. denial 3. anger 4. acceptance Correct Answer: 1 Rationale 1: Bargaining is an attempt to postpone or in some way affect the reality of the loss. Rationale 2: The brother is not expressing denial. Rationale 3: The brother does not appear to be angry. Rationale 4: The brother is not expressing acceptance. Global Rationale: Bargaining is an attempt to postpone or in some way affect the reality of the loss. The brother is not expressing denial or acceptance and does not appear to be angry. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 81 Question 2 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA A patient tells the nurse that her husband passed away a year ago and she is now beginning to realize that he is truly gone. The patient is planning to begin a new job and possibly move to a new community. The nurse realizes that this patient is in which stage of Bowlby’s theory of attachment? 1. detachment 2. protest 3. despair 4. anger Correct Answer: 1 Rationale 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. Rationale 2: The protest phase is marked by a lack of acceptance of the loss. Rationale 3: In despair, the person’s behavior becomes disorganized. Rationale 4: Anger is not a stage within Bowlby’s theory of attachment. Global Rationale: 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. The protest phase is marked by a lack of acceptance of the loss. In despair, the person’s behavior becomes disorganized. Anger is not a stage in Bowlby’s theory of attachment. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 80 Question 3 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient tells the nurse that since his wife died he has not been able to sleep and sees no reason to continue living. According to Freud’s theory on grief and loss, what should the nurse realize this patient is experiencing? 1. depression 2. grieving 3. emancipation 4. denial Correct Answer: 1 Rationale 1: According to Freud’s theory of grief and loss, the inability to grieve a loss results in depression. This is what the patient is experiencing by the inability to sleep and seeing no reason to continue living without his spouse. Rationale 2: Grieving is the inner labor of mourning a loss. The patient is not grieving. Rationale 3: Emancipation is not an element of Freud’s theory of grief and loss. Rationale 4: Denial is not element of Freud’s theory of grief and loss. Global Rationale: According to Freud’s theory of grief and loss, the inability to grieve a loss results in depression. This is what the patient is experiencing by the inability to sleep and seeing no reason to continue living without his spouse. Grieving is the inner labor of mourning a loss. The patient is not grieving. Emancipation and denial are not elements of Freud’s theory of grief and loss. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 80 Question 4 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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, the nurse identifies that this patient is in which stage? 1. restitution 2. acute grief 3. shock and disbelief 4. denial Correct Answer: 1 Rationale 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. Rationale 2: Acute grief is initiated by shock and disbelief. Rationale 3: Acute grief is initiated by shock and disbelief. Rationale 4: Acute grief is initiated by shock and disbelief, which may manifest as denial. Global Rationale: 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. The patient who is joining a support group is in the stage of restitution. Acute grief is initiated by shock and disbelief, which may manifest as denial. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 80 Question 5 Type: MCSA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Children this age recognize that death is permanent. 2. Children 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 this age think death is sleeping. Correct Answer: 1 Rationale 1: Age is a great determinant of beliefs about death. Children this age understand the finality of death. Rationale 2: At the age of 7, children do not have the emotional maturity to distance themselves from death. Rationale 3: The ability to understand separation has been mastered by the age of 7. Rationale 4: Children this age do not think that death is sleeping. Global Rationale: Age is a great determinant of beliefs about death. Children this age understand the finality of death. At the age of 7, children do not have the emotional maturity to distance themselves from death. The ability to understand separation has been mastered by the age of 7. Children this age do not think that death is sleeping. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 82 Question 6 Type: MCSA A patient of Native American descent is expected to die. The family arrives at the hospital and wants to observe their religious and cultural traditions. Which intervention by the nursing staff would be most appropriate? 1. Offer the family a private room to sit together. 2. Discourage the family from sitting with their loved one prior to death. 3. Discuss the possibility of transferring the patient home for the death. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Encourage the family to consider a DNR order. Correct Answer: 1 Rationale 1: Traditional Native Americans prefer to mourn in private, away from the dying patient. Rationale 2: It is not appropriate for the nurse to discourage the family from spending time with the patient at this critical point. Rationale 3: The severity of the patient’s condition does not allow for transfer at this time. Rationale 4: Some tribes prefer not to openly discuss DNR decisions. Global Rationale: Traditional Native Americans prefer to mourn in private, away from the dying patient. It is not appropriate for the nurse to discourage the family from spending time with the patient at this critical point. The severity of the patient’s condition does not allow for transfer at this time. Some tribes prefer not to openly discuss DNR decisions. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 84 Question 7 Type: MCSA A patient tells the nurse that her estranged husband 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.” Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: An ambivalent relationship prior to the loss can affect a person’s ability to grieve. Rationale 2: The patient does not seem angry. Rationale 3: It is inappropriate for the nurse to refer the patient to a therapist. Rationale 4: As the death occurred over a year ago, the patient is experiencing impaired grieving. Global Rationale: An ambivalent relationship prior to the loss can affect a person’s ability to grieve. The patient does not seem angry. It is inappropriate for the nurse to refer the patient to a therapist. As the death occurred over a year ago, the patient is experiencing impaired grieving. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 81 Question 8 Type: MCSA 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 with her thoughts. Correct Answer: 1 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Rationale 3: The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Rationale 4: The nurse should first use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Global Rationale: 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. The nurse should use the FICA assessment before implementing guided imagery, offering to pray with the patient, or leaving the patient alone to be with her thoughts. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 83 Question 9 Type: MCSA 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. Correct Answer: 1 Rationale 1: After death, the time must be recorded in the patient’s record. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: After documentation is completed, the attending physician will require notification. Rationale 4: The body can be transported to the morgue after family members have been notified and allowed to see their loved one. Global Rationale: After death, the time must be recorded in the patient’s record. After documentation is completed, the attending physician will require notification. 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. The body can be transported to the morgue after family members have been notified and allowed to see their loved one. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain the physiologic basis for manifestations associated with the end of life. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 88 Question 10 Type: MCSA 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. Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Gentle massage helps with accumulating edema of the extremities. Rationale 3: Small sips of fluids help with the discomfort of drying oral mucous membranes. Rationale 4: Oral care helps with the discomfort of drying oral mucous membranes. Global Rationale: 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. Gentle massage helps with accumulating edema of the extremities. Small sips of fluids and oral care help with the discomfort of drying oral mucous membranes. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 87 Question 11 Type: MCSA A terminally ill patient is experiencing dyspnea and tells the nurse that he feels like he is suffocating. 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. Correct Answer: 1 Rationale 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. Rationale 2: Raising the temperature in the room will not reduce the feeling of suffocation. Rationale 3: Providing additional intravenous fluids may contribute to fluid accumulation in the lungs and contribute to the feeling of suffocation.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The patient is terminally ill with dyspnea and therefore should not be ambulating or sitting out of bed. Global Rationale: Nursing care to improve respirations includes keeping the head of the bed elevated, keeping the room cool, and providing a breeze from a fan. Raising the temperature in the room will not reduce the feeling of suffocation. Providing additional intravenous fluids may contribute to fluid accumulation in the lungs and contribute to the feeling of suffocation. The patient is terminally ill with dyspnea and therefore should not be ambulating or sitting out of bed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 87 Question 12 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Increasing intravenous fluids could cause peripheral and lung edema. Rationale 3: Raising the head of the bed helps with dyspnea, not dehydration. Rationale 4: Enteral feedings could cause discomfort and would not help with the discomfort of a dry mouth and thirst. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Increasing intravenous fluids could cause peripheral and lung edema. Raising the head of the bed helps with dyspnea, not dehydration. Enteral feedings could cause discomfort and would not help with the discomfort of a dry mouth and thirst. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 87 Question 13 Type: MCSA A competent older adult patient has a living will stating that resuscitation and heroic life support measures are to be avoided. The 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. Correct Answer: 1 Rationale 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. Rationale 2: If there are concerns about the authenticity of the document, the Social Services department will need to be contacted. Rationale 3: If there are concerns about the authenticity of the document, the unit supervisor or hospital attorney will need to be contacted. Rationale 4: A lack of support by the family does not invalidate the document.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. If there are concerns about the authenticity of the document, the Social Services department, hospital attorney, or unit supervisor will need to be contacted. A lack of support by the family does not invalidate the document. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 85 Question 14 Type: MCSA At the time of admission, a patient with a terminal illness tells the nurse that her daughter will be allowed to make health-related decisions if she 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 Correct Answer: 1 Rationale 1: The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. Rationale 2: The living will provides written directions about life-prolonging decisions. Rationale 3: The durable power of attorney delegates the authority to make health, financial, and/or legal decisions on an individual’s behalf. Rationale 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, health care surrogates, and durable power of attorney.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The healthcare surrogate is an individual who will make medical decisions in the event the patient becomes unable to do so. The living will provides written directions about life-prolonging decisions. The durable power of attorney delegates the authority to make health, financial, and/or legal decisions on an individual’s behalf. 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. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 85 Question 15 Type: MCSA A terminally ill patient and the family agree that the physician will write a do-not-resuscitate order for the patient. The nurse understands that what should be implemented 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. Correct Answer: 1 Rationale 1: A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. Rationale 2: This order is based on the wishes of the patient and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest. Rationale 3: When implementing this order, the nurse would not call a code if the patient stops breathing or the heart stops beating. Rationale 4: Withholding food and fluids but providing pain medication would be elements of a comfortmeasures-only order. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: A do-not-resuscitate order is written by the physician for the patient who has a terminal illness or is near death. This order is based on the wishes of the patient and family that no cardiopulmonary resuscitation be performed for respiratory or cardiac arrest. When implementing this order, the nurse would not call a code if the patient stops breathing or the heart stops beating. Withholding food and fluids but providing pain medication would be elements of a comfort-measures-only order. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 85 Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: To initiate a slow code would be malpractice. Rationale 3: The nurse needs to call a code, not call the physician. Rationale 4: The nurse needs to call a code, not call the nursing supervisor. Global Rationale: Without an advance directive or do-not-resuscitate order, the nurse is legally responsible to call a code on the terminally ill patient who has stopped breathing. To initiate a slow code would be malpractice. The nurse needs to call a code, not call the physician or the nursing supervisor. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 85 Question 17 Type: MCSA While preparing for the discharge of a terminally ill older adult patient, the family asks for information concerning the most appropriate time to become involved with a hospice agency. Which action by the nurse is most correct? 1. Assist the family with making contact with a hospice agency at this time. 2. Determine the patient’s life expectancy to gauge when the contact should be made. 3. Encourage the family to “hold off” making the contact until death is very close. 4. Determine what expectations the family has of the hospice agency. Correct Answer: 1 Rationale 1: Hospice agencies provide vital services to patients who are facing death and to their families. Questions concerning available supportive services should be met with facts. Referrals for older patients should be prompt. Rationale 2: It is inappropriate to try to determine life expectancy. This is an inaccurate measurement of the degree of services needed. Rationale 3: Waiting until the time of death nears does not leave much time for the hospice agency to assist the family. Rationale 4: Determining the family’s expectations concerning hospice is an inappropriate action for the nurse. Global Rationale: Hospice agencies provide vital services to patients who are facing death and to their families. Questions concerning available supportive services should be met with facts. Referrals for older patients should be prompt. It is inappropriate to try to determine life expectancy. This is an inaccurate measurement of the degree LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
of services needed. Waiting until the time of death nears does not leave much time for the hospice agency to assist the family. Determining the family’s expectations concerning hospice is an inappropriate action for the nurse. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 4. Describe the philosophy and activities of hospice and palliative care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 86 Question 18 Type: MCSA A terminally ill patient is receiving palliative care. What does the nurse understand the purpose of this type of care to be? 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 Correct Answer: 1 Rationale 1: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. Rationale 2: Medical complications can be controlled but not prevented. Rationale 3: The purpose is not specifically to postpone death. Rationale 4: Withdrawing all medical care would be inappropriate as it would cause more suffering. Global Rationale: The purpose of palliative care is to provide comprehensive care focused on alleviating suffering and enhancing quality of life. Medical complications can be controlled but not prevented. The purpose is not specifically to postpone death. Withdrawing all medical care would be inappropriate as it would cause more suffering. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 4. Describe the philosophy and activities of hospice and palliative care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 86 Question 19 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Hospice care focuses on comfort care versus curative care. Rationale 2: The focus of hospice is on care, not cure. It is care for patients with limited life expectancy. Rationale 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. Rationale 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. Global Rationale: Hospice care focuses on comfort care versus curative care. It is care for patients with limited life expectancy. 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. 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. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & family for relief of pain, discomfort, or suffering LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; 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: 4. Describe the philosophy and activities of hospice and palliative care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 86 Question 20 Type: MCSA A patient with 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.” Correct Answer: 1 Rationale 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. Rationale 2: In palliative care, the nurse needs to be honest with the patient and explain that the medication will not cure the disease. Rationale 3: The nurse should not approach care as curative because this could rob the patient of time and closure at the end of life. Rationale 4: The nurse has no way of knowing whether the medication will help or hurt the patient. Global Rationale: 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. The nurse should not approach care as curative because this could rob the patient of time and closure at the end of life. The nurse has no way of knowing whether the medication will help or hurt the patient. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B.6. Elicit expectations of patient & family for relief of pain, discomfort, or suffering
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; 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: 4. Describe the philosophy and activities of hospice and palliative care. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 86 Question 21 Type: SEQ A patient is explaining her experiences after the sudden death of her daughter 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. “I have to admit I tried to make a deal with God to bring her back to me.” Choice 2. “I’m going to try to use my experience with her illness to help other parents.” Choice 3. “I cannot get my mind around it. I still keep waiting for her to come home from school.” Choice 4. “I can hardly get out of bed because I just want to sleep.” Choice 5. “I just feel so mad at her for leaving me!” Correct Answer: 3,5,1,4,2 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. The stages are denial, anger, bargaining, depression, and finally acceptance. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 81 Question 22 Type: MCMA The nurse is caring for a patient who is nearing death from a terminal illness. The patient is experiencing secretions in the back of the throat and dyspnea. Which medications should the nurse provide to assist this patient? Standard Text: Select all that apply. 1. Oxygen 2. Morphine 3. Atropine 4. Scopolamine 5. Demerol Correct Answer: 1, 2, 3, 4 Rationale 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. Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
who are well hydrated, and in those who are having difficulty swallowing or coughing. These manifestations may be treated with opioids. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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, opioids, and medications that reduce secretions, such as atropine and scopolamine. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; 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. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 87 Question 23 Type: MCMA The sibling of a patient who is nearing death has insisted on intravenous fluids because “My brother wants to live.” Which findings should the nurse expect when assessing this patient? Standard Text: Select all that apply. 1. The nurse notes the presence of inspiratory and expiratory crackles in all lung fields. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. The nurse notes that there is increasing edema in the patient’s ankles and feet bilaterally. 3. The patient has developed ascites. 4. The patient has lost 6 pounds from last week. 5. The nurse learns during shift report that the patient vomited three times during the night shift. Correct Answer: 1,2,3,5 Rationale 1: Initiating intravenous fluids for hydration purposes in the dying patient may increase fluid in the lungs. Rationale 2: Initiating intravenous fluids for hydration purposes in the dying patient may lead to peripheral edema. Rationale 3: Initiating intravenous fluids for hydration purposes in the dying patient may lead to ascites. Rationale 4: The patient is much less likely to lose weight at this time. Rationale 5: Initiating intravenous fluids for hydration purposes in the dying patient may lead to vomiting. Global Rationale: Initiating intravenous fluids for hydration purposes in the dying patient may increase fluid in the lungs, peripheral edema, ascites, and vomiting. The patient is much less likely to lose weight at this time. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; 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. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 87 Question 24 Type: MCMA A patient of Mexican American descent is dying. Which statements by the patient’s only son are expected? Standard Text: Select all that apply. 1. “We have already notified our priest about Dad’s condition.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 1,3,4,5 Rationale 1: It is important that the patient’s priest be notified. Rationale 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. Rationale 3: Pregnant women do not care for dying persons or attend funerals. Rationale 4: Extended family members are obligated to pay respects to the sick and dying. Rationale 5: Based on the belief that worry may make health worse, the family may want to protect the patient from the seriousness of illness. The information is often handled by an older daughter or son. Global Rationale: It is important that the patient’s priest be notified. Pregnant women do not care for dying persons or attend funerals. Extended family members are obligated to pay respects to the sick and dying. Based on the belief that worry may make health worse, the family may want to protect the patient from the seriousness of illness. The information is often handled by an older daughter or son. 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. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 84 Question 25 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse, reviewing data for a patient receiving hospice, believes death is imminent. Which manifestations of impending death did the nurse observe on the patient’s medical record? (Review the information provided from the patient’s medical record.)
1. vital signs and skin appearance 2. vital signs and output 3. vital signs and intake 4. vital signs and lung sounds Correct Answer: 1 Rationale 1: Manifestations of impending death include weak, slow, and/or irregular pulse; decrease in blood pressure; and cool, mottled, and cyanotic skin. Rationale 2: The patient may also experience incontinence of bowel and bladder. Rationale 3: As the patient has not been incontinent, of the choices, the signs of pending death would be the patient’s vital signs and skin appearance. Rationale 4: Coarse lung sounds are normal due to the accumulation of fluid. Global Rationale: Manifestations of impending death include weak, slow and/or irregular pulse; decrease in blood pressure; and cool, mottled, and cyanotic skin. Coarse lung sounds are normal due to the accumulation of LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
fluid. The patient may also experience incontinence of bowel and bladder. As the patient has not been incontinent, of the choices, the signs of pending death would be the patient’s vital signs and skin appearance. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; 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. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 86 Question 26 Type: MCHS A patient in the final stages of colon cancer is demonstrating Cheyne-Stokes respirations. To assess these respirations, the nurse should auscultate breath sounds over which area of the thorax? (Click the cursor over the location where the stethoscope should be placed.)
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Breath sounds are auscultated over the lung fields. The upper red areas would be associated with the shoulder regions. The lower right red area is over the liver. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 87 Question 27 Type: SEQ A patient diagnosed with testicular cancer tells the nurse that he 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. Standard Text: Click and drag the options below to move them up or down. Choice 1. depression LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Choice 2. acceptance Choice 3. anger Choice 4. denial Choice 5. bargaining Correct Answer: 4,3,5,1,2 Rationale 1: The fourth stage, depression, occurs when the patient realizes the full impact of the loss. Rationale 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. Rationale 3: The second stage is anger, when the patient demonstrates anger over the situation. Rationale 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. Rationale 5: The third stage is bargaining, in which the patient may make an agreement with God or another supreme being. Global Rationale: The patient is currently in the stage of denial by refusing to accept the diagnosis. KüblerRoss’s stages of grieving begin with denial. The second stage is anger, when the patient demonstrates anger over the situation. The third stage is bargaining, in which the patient may make an agreement with God or another supreme being. The fourth stage, depression, occurs when the patient realizes the full impact of the loss. 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. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 81 Question 28 Type: FIB LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient being treated for terminal cancer is prescribed morphine sulfate through a continuous intravenous infusion. The pharmacy is requesting the patient’s current weight in kilograms. During the last measurement, the patient’s weight was documented as 128 lbs. What should the nurse calculate this patient’s weight in kg to be? Standard Text: Correct Answer: 58.1 Rationale: To calculate the patient’s weight in kilograms, the nurse should divide the weight in pounds by 2.2. This calculation would be 128/2.2 = 58.1 kg. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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: Quality and Safety; Knowledge; Current Best Practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: Page Number: 85 Question 29 Type: FIB A patient diagnosed with pancreatic cancer is prescribed strict intake and output. During the last shift, the patient received 1 liter of 0.9% normal saline; two 50-milliliter doses of morphine sulfate in 0.9% normal saline; 3 ounces water. What should the nurse calculate this patient’s total intake for the previous shift to be? Standard Text: Correct Answer: 1,190 Rationale: To calculate the patient’s total intake, 1 liter of 0.9% normal saline is 1,000 mL. Add this to 100 mL for the two doses of morphine sulfate to equal 1,100 mL. The oral intake of 3 ounces is converted to 90 mL (1 ounce = 30 mL). The patient’s total intake for the previous shift was 1,190 mL. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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: Quality and Safety; Knowledge; Current Best Practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 86 Question 30 Type: MCMA The nurse suspects a patient is in the final stages of the dying process. What manifestations did the nurse assess in this patient? Standard Text: 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 Correct Answer: 1,3,5 Rationale 1: Assessment findings consistent with the late stages of the dying process include a change in level of consciousness. Rationale 2: There is a decrease, not an increase, in taste and smell. Rationale 3: Assessment findings consistent with the late stages of the dying process include incontinence of bowel and bladder. Rationale 4: Blood pressure will decrease. Rationale 5: Assessment findings consistent with the late stages of the dying process include an irregular heart rate. Global Rationale: Assessment findings consistent with the late stages of the dying process include a change in level of consciousness, incontinence of bowel and bladder, and an irregular heart rate. There is a decrease, not an increase, in taste and smell. Blood pressure will decrease. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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 and Safety; Knowledge; Current Best Practices Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 86 Question 31 Type: MCMA A patient diagnosed with terminal cancer tells the nurse that she knows everything about a living will. Upon assessment, the nurse realizes the patient needs additional instruction on this type of advance directive when the patient makes which statements? Standard Text: 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.” Correct Answer: 1,2,4,5 Rationale 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. Rationale 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. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 5: A living will is not created by the patient’s family. Global Rationale: 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. 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. 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. A living will is not created by the patient’s family and cannot be modified by the family. A living will is not created for another person; therefore, the family cannot make a living will for a patient. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: Page Number: 85 Question 32 Type: MCMA 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? Standard Text: 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.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2,3,5 Rationale 1: Hospice care can be received in the home, hospital, hospice center, or community. Rationale 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. Rationale 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. Rationale 4: Hospice care can be received in the home, hospital, hospice center, or community. Rationale 5: Hospice care can be received either at home, the hospital, hospice center, or the community. Global Rationale: 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. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.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 and Safety; Knowledge; Current Best Practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe the philosophy and activities of hospice and palliative care. MNL Learning Outcome: Page Number: 86 Question 33 Type: MCMA A young adult male patient diagnosed with terminal pancreatic cancer tells the nurse that if he lets his hair grow, God will cure him. What should the nurse realize this patient is demonstrating? Standard Text: 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 2,4 Rationale 1: The patient is not delusional and is not using religious beliefs to block the loss. Rationale 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. Rationale 3: The patient is also not in denial and using his religious beliefs to block the loss. Rationale 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. Rationale 5: Bargaining with God is not a demonstration of anger. Global Rationale: 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. The patient is not delusional or in denial and is not using religious beliefs to block the loss. Bargaining with God is not a demonstration of anger. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: 3.3.1. Utilize the nursing process in care of client. Page Number: 81 Question 34 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. The patient is in denial. 4. The patient is forgetting about the disease that caused the loss of the limb. Correct Answer: 1 Rationale 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. Rationale 2: The patient’s actions indicate a positive adaptation, not an inability to manage grief. Rationale 3: Denial is manifested by behaviors or statements indicating the patient cannot believe the event has occurred. Rationale 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. Global Rationale: 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. The patient’s actions indicate a positive adaptation, not an inability to manage grief. Denial is manifested by behaviors or statements indicating the patient cannot believe the event has occurred. 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. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 80 Question 35 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient who has just lost her spouse asks the nurse how long it will be until she feels like living again. The nurse realizes this patient has to work through which phases of the grieving process according to Bowlby? Standard Text: Select all that apply. 1. denial 2. despair 3. detachment 4. protest 5. restitution Correct Answer: 2,3,4 Rationale 1: Denial is associated with feelings of disbelief. Rationale 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 she has acknowledged the event. Rationale 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 she has acknowledged the event. Rationale 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 she has acknowledged the event. Rationale 5: Restitution is a stage in Engel’s theory of loss. Global Rationale: 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 she has acknowledged the event. Denial is associated with feelings of disbelief. Restitution is a stage in Engel’s theory of loss. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; Promote and accept the patient's emotions; accept and respond to distress in patient and self; facilitate hope, trust, and faith LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 80 Question 36 Type: MCSA The spouse of a former patient tells the nurse that he has joined a support group to help with the loss of his wife. The nurse realizes this patient is in which phase of Engel’s grief process? 1. acute 2. restitution 3. long-term 4. resolution Correct Answer: 2 Rationale 1: The acute phase is initiated by shock and disbelief, manifested by denial. Rationale 2: According to Engel, there are three phases of the grief process: acute, restitution, and long-term. It is during restitution that the surviving spouse might join a support group to help cope with the loss. Rationale 3: During the long-term phase, the individual begins to come to terms with the loss and renew activities. Rationale 4: Resolution is associated with the acceptance of the loss but is not one of the phases in Engel’s grief process. Global Rationale: 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. The acute phase is initiated by shock and disbelief, manifested by denial. During the long-term phase, the individual begins to come to terms with the loss and renew activities. Resolution is associated with the acceptance of the loss but is not one of the phases in Engel’s grief process. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Relationship Centered Care; Practice; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 80 Question 37 Type: MCSA A patient tells the nurse, “I dread going on after the divorce is final. I have no idea how I am going to manage financially or emotionally.” The nurse realizes this patient is demonstrating which aspect of Caplan’s stress and loss theory? 1. living without the assets and guidance 2. psychic pain 3. reduced problem-solving ability 4. emotional turmoil Correct Answer: 1 Rationale 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.” Rationale 2: Psychic pain encompasses the loss of the bond and the pain associated with coming to terms with the loss. Rationale 3: The patient is not demonstrating an inability to handle her problems according to the data provided. Rationale 4: Emotional turmoil is not a specific factor cited in Caplan’s theory. Global Rationale: 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.” Psychic pain encompasses the loss of the bond and the pain associated with coming to terms with the loss. The patient is not demonstrating an inability to handle her problems according to the data provided. Emotional turmoil is not a specific factor cited in Caplan’s theory. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 81 Question 38 Type: MCSA A patient who is a recent widow states, “I wanted to ask him for a divorce and then he died.” What should the nurse realize this patient is at risk for developing? 1. an accelerated grief reaction 2. a dysfunctional grief reaction 3. a typical grief reaction process 4. psychosomatic disorders Correct Answer: 1 Rationale 1: Factors that can interfere with a successful grieving reaction include ambivalent relationships prior to the loss. Rationale 2: This statement does not necessarily indicate that a dysfunctional grief reaction. Rationale 3: The patient’s intentions may prevent a typical grief reaction. Rationale 4: This statement does not necessarily indicate that the patient may develop a psychosomatic disorder. Global Rationale: Factors that can interfere with a successful grieving reaction include ambivalent relationships prior to the loss. This statement does not necessarily indicate a dysfunctional grief reaction or the likelihood of a psychosomatic disorder. The patient’s intentions may prevent a typical grief reaction. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Relationship Centered Care; Practice; 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: 1. Explain how theories of loss and grief influence provision of patient-centered care for individuals experiencing loss, grief, and death. MNL Learning Outcome: Page Number: 81 Question 39 Type: MCSA 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 Correct Answer: 3 Rationale 1: This patient statement does not indicate coping. Rationale 2: This patient statement does not indicate denial. Rationale 3: Regional differences in the way death is expressed in the United States include “passed away,” “went to be with God,” and “passed from this life.” Rationale 4: This patient statement does not reflect a cultural rite. Global Rationale: Regional differences in the way death is expressed in the United States include “passed away,” “went to be with God,” and “passed from this life.” This statement does not reflect coping, denial, or a cultural rite. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 82 Question 40 Type: MCSA 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 Correct Answer: 2 Rationale 1: ABC represents airway, breathing, and circulation, and is not related to assessing a dying patient’s spiritual beliefs about death. Rationale 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. Rationale 3: DABDA represents denial, anger, bargaining, despair, and acceptance and are Kübler-Ross’s stages of grieving. Rationale 4: RACE represents the emergency evacuation procedure during a fire: remove, activate, confine, and extinguish. This acronym is not related to this situation. Global Rationale: Faith, influence, community, and address form the acronym FICA. These topics can help the nurse move through the spiritual assessment process with a patient. ABC represents airway, breathing, and circulation, and is not related to assessing a dying patient’s spiritual beliefs about death. DABDA represents denial, anger, bargaining, despair, and acceptance and are Kübler-Ross’s stages of grieving. RACE represents the emergency evacuation procedure during a fire: remove, activate, confine, and extinguish. This acronym is not related to this situation. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Relationship Centered Care; Practice; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 83 Question 41 Type: MCSA The 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 Correct Answer: 2 Rationale 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 health care. Rationale 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. Rationale 3: Durable power of attorney does not confer decision-making power related to health. This specifically needs to be a healthcare power of attorney. Rationale 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 health care. Global Rationale: 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. 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 health care. Durable power of attorney does not confer decision-making power related to health. This specifically needs to be a healthcare power of attorney. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & family for relief of pain, discomfort, or suffering
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: Page Number: 85 Question 42 Type: MCSA 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. Correct Answer: 2 Rationale 1: Nursing care to improve respirations does not include lowering the head of the bed. Rationale 2: Nursing care to improve respirations includes raising the head of the bed. Rationale 3: Suctioning would be considered an advanced care measure and is not indicated in the scenario. Rationale 4: Chest physiotherapy would be considered an advanced care measure and is not indicated in the scenario. Global Rationale: Nursing care to improve respirations includes raising, not lowering, the head of the bed. Suctioning and chest physiotherapy would be considered advanced care measures and are not indicated in the scenario. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 87 Question 43 Type: MCSA The family of a dying patient states, “She has to be in pain, because all she does is moan.” 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 Correct Answer: 3 Rationale 1: The responses by the family are typical and do not reflect excessive concern. Rationale 2: There is no indication that the family is requesting pain medication. Rationale 3: Moaning, groaning, and grimacing often accompany agitation and may be misinterpreted as pain. Rationale 4: The family thinks she is in pain, which would not indicate an improvement in status. Global Rationale: Moaning, groaning, and grimacing often accompany agitation and may be misinterpreted as pain. The family thinks she is in pain, which would not indicate an improvement in status. The responses by the family are typical and do not reflect excessive concern. There in no indication that the family is requesting pain medication. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 87 Question 44 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A dying patient tells the nurse, “Don’t let my family leave me.” 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 Correct Answer: 1 Rationale 1: Family members are often afraid to be present at the time of death, yet dying alone is the greatest fear expressed by patients. Rationale 2: There is no information provided to indicate there will be a recovery or improvement in the patient’s condition. Rationale 3: There is no information provided to indicate there will be a recovery or improvement in the patient’s condition. Rationale 4: While the patient may wish to live longer, these behaviors are consistent with a fear of dying alone. Global Rationale: Family members are often afraid to be present at the time of death, yet dying alone is the greatest fear expressed by patients. There is no information provided to indicate there will be a recovery or improvement in the patient’s condition. While the patient may wish to live longer, these behaviors are consistent with a fear of dying alone. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 88 Question 45 Type: MCSA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. empathy 2. apathy 3. overemotionality 4. blunting Correct Answer: 4 Rationale 1: Empathy refers to the provision of emotional support that promotes a feeling of acceptance to the patient. Rationale 2: Apathy is an emotion characterized by a lack of concern and involvement. Rationale 3: Overemotionality is not a recognized term. Rationale 4: Blunting is a problem often experienced by nurses who provide care to the terminally ill. The nurse may not be able to handle his or her emotions appropriately right after the death, and this is a coping mechanism. Global Rationale: Blunting is a problem often experienced by nurses who provide care to the terminally ill. The nurse may not be able to handle his or her emotions appropriately right after the death, and this is a coping mechanism. Empathy refers to the provision of emotional support that promotes a feeling of acceptance to the patient. Apathy is an emotion characterized by a lack of concern and involvement. Overemotionality is not a recognized term. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 88 Question 46 Type: MCSA A patient who has recently loss his spouse states, “I just can’t cry.” What should the nurse realize this patient is at risk for developing? 1. psychological issues LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. depression 3. overemotionality 4. somatic symptoms Correct Answer: 4 Rationale 1: There is no indication this patient will face an increased risk for the development of psychological issues. Rationale 2: There is no indication this patient will face an increased risk for the development of depression. Rationale 3: Crying is considered a typical and expected part of the grief reaction in most grief theories. Rationale 4: The inability to express grief can lead to the onset of somatic, or physical, symptoms. Global Rationale: The inability to express grief can lead to the onset of somatic, or physical, symptoms. Crying is considered a typical and expected part of the grief reaction in most grief theories. There is no indication this patient will face an increased risk for the development of psychological issues or depression. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 89 Question 47 Type: MCSA A preoperative patient says to the nurse, “I hope I wake up after surgery. I don’t know what my family would do if I didn’t.” The nurse realizes this patient is demonstrating which potential problem? 1. coping 2. chronic sorrow 3. anticipatory grieving 4. death anxiety LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 3 Rationale 1: This patient is expressing a feeling, not demonstrating coping. Rationale 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.” Rationale 3: Anticipatory grieving is a combination of intellectual and emotional responses and behavior by which people adjust their self-concept in the face of a potential loss. Rationale 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. Global Rationale: Anticipatory grieving is a combination of intellectual and emotional responses and behavior by which people adjust their self-concept in the face of a potential loss. This patient is expressing a feeling, not demonstrating coping. 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.” 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. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 81 Question 48 Type: MCMA A patient with a terminal illness says that when the pain becomes too unbearable he plans to take an overdose of pain medication and end it all. How should the nurse respond to this patient’s plan? Standard Text: Select all that apply. 1. “Do you have a living will?” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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?” Correct Answer: 1, 2, 3, 5 Rationale 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. Rationale 2: Durable power of attorney is a document that can delegate the authority to make healthcare decisions. Rationale 3: A healthcare surrogate is a person selected to make medical decisions when the patient is no longer able to do so. Rationale 4: Euthanasia is not supported by the American Nurses Association and would be inappropriate to discuss with the patient. Rationale 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. Global Rationale: 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. Durable power of attorney is a document that can delegate the authority to make healthcare decisions. A healthcare surrogate is a person selected to make medical decisions when the patient is no longer able to do so. A physician order for lifesustaining treatment (POLST) is a form for patients with serious, progressive, chronic illnesses that translates their wishes regarding life-sustaining treatment into actionable medical orders. Euthanasia is not supported by the American Nurses Association and would be inappropriate to discuss with the patient. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.B.6. Elicit expectations of patient & 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; 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: 3. Analyze common legal and ethical issues in end-of-life care. MNL Learning Outcome: Page Number: 85 Question 49 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient who nearing the end of life is irritable and uncomfortable in bed. Which actions should the nurse take to make the patient more comfortable? Standard Text: 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. Correct Answer: 1, 2, 3, 5 Rationale 1: Actions to help this patient achieve comfort include raising the head of the bed. Rationale 2: Actions to help this patient achieve comfort include applying bed pads over the linens. Rationale 3: Actions to help this patient achieve comfort include gently massaging the extremities. Rationale 4: Reducing the amount of pain medication can increase this patient’s level of pain. Rationale 5: Actions to help this patient achieve comfort include using a draw sheet when turning. Global Rationale: Actions to help this patient achieve comfort include raising the head of the bed, applying bed pads over the linens, gently massaging the extremities, and using a draw sheet when turning. Reducing the amount of pain medication can increase this patient’s level of pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 87 Question 50 Type: MCMA A patient with a terminal illness is experiencing severe nausea and vomiting. Which medications should the nurse consider appropriate for the patient at this time? Standard Text: Select all that apply. 1. Furosemide (Lasix) LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Ondansetron (Zofran) 3. Meperidine (Demerol) 4. Morphine sulfate (Morphine) 5. Prochlorperazine (Compazine) Correct Answer: 2, 5 Rationale 1: Furosemide (Lasix) is a diuretic. Rationale 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. Rationale 3: Meperidine (Demerol) is an analgesic that can metabolize into products that could lead to seizure activity. Rationale 4: Morphine sulfate (Morphine) is an analgesic, which could be causing this patient’s nausea and vomiting. Rationale 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. Global Rationale: 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. Furosemide (Lasix) is a diuretic. Meperidine (Demerol) is an analgesic that can metabolize into products that could lead to seizure activity. Morphine sulfate (Morphine) is an analgesic, which could be causing this patient’s nausea and vomiting. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.B.6. Elicit expectations of patient & 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 and Safety; Knowledge; Current best practices Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Describe the physiologic responses associated with the end of life. MNL Learning Outcome: Page Number: 87 Question 51 Type: MCMA A patient whose spouse passed away 5 years ago becomes severely depressed on holidays, anniversaries, and birthdays. What should the nurse do to help this patient? Standard Text: Select all that apply. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Encourage the patient to talk with family or spiritual support systems. 2. Explain that these feelings are a sign of chronic depression. 3. Help the patient talk about the loss and hopes for the future. 4. Explain that these feelings will last as long as the patient is alive. 5. Role-play ways for the patient to get through the days when depression is the worst. Correct Answer: 1, 3, 4, 5 Rationale 1: For the patient with chronic sorrow the nurse should encourage the patient to talk with family or others in the patient’s spiritual support system. Rationale 2: These feelings are not a sign of chronic depression. Rationale 3: For the patient with chronic sorrow the nurse should encourage the patient to talk about the loss and hopes for the future. Rationale 4: For the patient with chronic sorrow the nurse should explain that these feelings will last as long as the patient is alive. Rationale 5: For the patient with chronic sorrow the nurse should role-play ways for the patient to get through the days when the depression is the worst. Global Rationale: For the patient with chronic sorrow the nurse should encourage the patient to talk with family or others in the patient’s spiritual support system, help the patient talk about the loss and hopes for the future, explain that these feelings will last as long as the patient is alive, and role-play ways for the patient to get through the days when the depression is the worst. These feelings are not a sign of chronic depression. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 92 Question 52 Type: MCMA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: Evidence that grief is resolving includes not living in the past. Rationale 2: Evidence that grief is resolving includes breaking ties with the lost person. Rationale 3: Asking for help to end the pain of the loss indicates that grief resolution is not occurring. Rationale 4: Evidence that grief is resolving includes experiencing waves of sadness when looking at a picture. Rationale 5: Wishing for death at the same time that the spouse died indicates that grief resolution is not occurring. Global Rationale: Evidence that grief is resolving includes not living in the past, breaking ties with the lost person, and experiencing waves of sadness when looking at a picture. Asking for help to end the pain of the loss and wishing for death at the same time that the spouse died indicates that grief resolution is not occurring. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; 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: 2. Explain factors affecting patient and family responses to loss. MNL Learning Outcome: Page Number: 92
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff, Medical-Surgical Nursing 6th Edition Test Bank Chapter 6 Question 1 Type: MCSA A patient tells the nurse that both of his parents are alcoholics and wonders about the likelihood of becoming an alcoholic as well. 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.” Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not question the patient’s request for information about becoming an alcoholic like his parents. Rationale 3: Although the patient does have an increased risk, stating that he will become an alcoholic is inappropriate. Rationale 4: Telling the patient not to worry about becoming an alcoholic is an inappropriate response. Global Rationale: Genetic studies have been performed that suggest heredity plays a role in the development of alcoholism. The nurse should respond that that there are studies that support this link. The nurse should not question the patient’s request for information about becoming an alcoholic like his parents. Although the patient does have an increased risk, stating that he will become an alcoholic is inappropriate. Telling the patient not to worry about becoming an alcoholic is also an inappropriate response. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: Page Number: 97-98
Question 2 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: There is not enough information to support that the patient is spending time drinking with friends. Rationale 3: There is not enough information to support that the patient is consuming alcohol as a symptom of stress. Rationale 4: There is also not enough evidence to support this patient’s alcohol use as being a learned behavior. Global Rationale: 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. There is not enough information to support that the patient is spending time drinking with friends or the patient is consuming alcohol as a symptom of stress. There is also not enough evidence to support this patient’s alcohol use as being a learned behavior. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. 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, LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
using a constructed pedigree from collected family history information as well as standardized symbols and terminology NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: Page Number: 97-98
Question 3 Type: MCSA A patient tells the nurse that she started to have a glass of wine every evening at home after work to “unwind” and then realized that she cannot continue with her day unless she has the wine. The nurse realizes that this patient uses wine to 1. cope with day-to-day problems. 2. deal with difficulty expressing emotions. 3. suppress a genetic need for alcohol. 4. socialize with others. Correct Answer: 1 Rationale 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. Rationale 2: There is no information to suggest that the patient is having difficulty expressing emotions. Rationale 3: There is no information to suggest that the patient has a genetic need for alcohol. Rationale 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. Global Rationale: 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.There is no information to suggest that the patient is having difficulty expressing emotions or has a genetic need for alcohol. The patient is drinking at home after work, so there is no information to support the patient is using alcohol to socialize with others. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: Page Number: 99
Question 4 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: There is no information to support the concept that an individual with type 2 diabetes would avoid alcohol. Rationale 3: There is no information to support the concept that an individual with 2 children would avoid alcohol. Rationale 4: There is no information to support the concept that an individual employed as an accountant would avoid alcohol. Global Rationale: 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
There is no information to support the concept that an individual with type 2 diabetes, 2 children, or employment as an accountant would avoid alcohol. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: 1.A. 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: Page Number: 99
Question 5 Type: MCSA A nurse is concerned about potential substance abuse by a coworker. What behavior warrants further investigation? 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. Correct Answer: 1 Rationale 1: Excessive medication wasting could be a sign that a nurse is using or diverting drugs. Rationale 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. Rationale 3: Requesting not to be the medication nurse would reduce access to potentially abusive substances. Rationale 4: Taking frequent or lengthy breaks might signal substance abuse. Declining scheduled breaks is not characteristic of a substance abuser.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Excessive medication wasting could be a sign that a nurse is using or diverting drugs. 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. Requesting not to be the medication nurse would reduce access to potentially abusive substances. Taking frequent or lengthy breaks might signal substance abuse. Declining scheduled breaks is not characteristic of a substance abuser. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
Question 6 Type: MCSA A nurse consistently arrives to work wearing a long-sleeved blouse despite the temperature being in the 90s and the air humid. When colleagues mention her attire, the nurse becomes defensive and isolates herself from others. What does the nurse’s behavior suggest? 1. substance abuse 2. a long-standing illness 3. introverted behavior 4. low self-esteem Correct Answer: 1 Rationale 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. Rationale 2: There is not enough information to support the idea that the nurse has a long-standing illness. Rationale 3: There is also not enough information to support the idea that the nurse routinely engages in introverted behavior. Rationale 4: There is not enough information to support the idea that the nurse has low self-esteem.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Signs of drug use include wearing long sleeves in hot weather to cover up arms defensive behavior, and isolation. There is not enough information to support idea that the nurse has a long-standing illness, routinely engages in introverted behavior, or has low self-esteem. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
Question 7 Type: MCMA The nurse manager is concerned that one staff nurse is demonstrating signs of substance abuse. Which behaviors did the manager observe in the staff nurse? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 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. Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 4: Volunteering to transfer a patient to the intensive care unit is not an indication of substance abuse. Rationale 5: Following up with nursing assistants on patient care needs is not an indication of substance abuse. Global Rationale: 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, frequently using the bathroom, and excessive use of mouthwash. Volunteering to transfer a patient to the intensive care unit or following up with nursing assistants on patient care needs are not indications of substance abuse. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
Question 8 Type: MCSA 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. Correct Answer: 1 Rationale 1: Leaving the unit and not being located for long periods of time are indicative of depression associated with substance abuse. Rationale 2: Using the visitor bathroom instead of employee bathroom is not necessarily an indication that the nurse is experiencing depression because of substance abuse. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Eating lunch away from the hospital is not an indication that the colleague is experiencing depression from substance abuse. Rationale 4: Complaining of a headache is not necessarily an indication that the colleague is experiencing depression from substance abuse. Global Rationale: Leaving the unit and not being located for long periods of time are indicative of depression associated with substance abuse. Using the visitor bathroom instead of employee bathroom, eating lunch away from the hospital, and complaining of headaches at work are not indicative of the colleague experiencing depression because of substance abuse. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
Question 9 Type: MCSA A patient recovering from outpatient carpal tunnel surgery returns to the surgical center the next day and tells the nurse that she is having trouble attending to daily activities and the pain is “excruciating,” so she 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. A nerve was cut during the procedure. 3. The patient was not given strong enough postoperative pain medication. 4. The patient is under stress to return to work. Correct Answer: 1 Rationale 1: Abusers often have a low tolerance for frustration and pain. Since the patient had surgery the day before and returns to the center reporting frustration and excruciating pain and demanding more pain medication, this could indicate that the patient has a substance abuse problem. Rationale 2: There would be a sensorimotor deficit if the nerve had been cut during the procedure. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: There is not enough information to determine whether the patient was not given strong enough postoperative pain medication. Rationale 4: There is not enough information to determine whether the patient is under stress to return to work. Global Rationale: Abusers often have a low tolerance for frustration and pain. Since the patient had surgery the day before and is now reporting excruciating pain and demanding more pain medication, this could indicate that the patient has a substance abuse problem. There would be a sensorimotor deficit if the nerve had been cut during the procedure. There is not enough information to determine whether the patient was not given strong enough postoperative pain medication or whether the patient is under stress to return to work. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe common characteristics of people with substance abuse problems. MNL Learning Outcome: Page Number: 99-100
Question 10 Type: MCSA A patient complaining of back pain tells the nurse that he needs several refills on any prescription since he takes the medication 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. Correct Answer: 1 Rationale 1: Addictive behavior associated with substance use is characterized by loss of control over consumption. The patient states that he is taking the medication more frequently that prescribed, which could indicate a loss of control. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: There is no evidence that the patient is being impulsive. Rationale 3: There is no evidence that the patient is using the pain medication to fit in with a peer group. Rationale 4: There is no evidence that the patient is using the pain medication to overcome low self-esteem. Global Rationale: Addictive behavior associated with substance use is characterized by loss of control over consumption. The patient states that he is taking the medication more frequently that prescribed, which could indicate a loss of control. There is not enough information to support the idea that the patient is being impulsive, is using the pain medication to fit in with a peer group, or is using the pain medication to overcome low selfesteem. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe common characteristics of people with substance abuse problems. MNL Learning Outcome: Page Number: 99-100
Question 11 Type: MCSA A patient is brought into the emergency department with a gunshot wound obtained 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 Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Cardiovascular disease is not usually manifested by engagement in risk-taking behavior. Rationale 3: Respiratory disease is not usually manifested by engagement in risk-taking behavior. Rationale 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. Global Rationale: 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. Cardiovascular disease and respiratory disease are not usually manifested by engagement in risk-taking behavior. 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. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe common characteristics of people with substance abuse problems. MNL Learning Outcome: Page Number: 99-100
Question 12 Type: MCSA A patient tells the nurse that he becomes very angry and abusive to his friends and family when he is 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?” Correct Answer: 1 Rationale 1: The patient demonstrates anger and abusive behavior when unable to obtain an illegal substance. This information should indicate to the nurse that the patient has a substance abuse problem. The best response for the nurse to make is to ask the patient if he has considered seeking treatment for this behavior. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The nurse should not comment on the patient’s number of friends. Rationale 3: Asking if the patient is argumentative at work could incite the patient’s anger and abusiveness. Rationale 4: Asking the patient about his family could incite the patient’s anger. Global Rationale: The patient demonstrates anger and abusive behavior when unable to obtain an illegal substance. This information should indicate to the nurse that the patient has a substance abuse problem. The best response for the nurse to make is to ask the patient if he has considered seeking treatment for this behavior. The nurse should not comment on the patient’s number of friends. Asking if the patient is argumentative at work could incite the patient’s anger and abusiveness. Asking the patient about his family could incite the patient’s anger. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe common characteristics of people with substance abuse problems. MNL Learning Outcome: Page Number: 99-100
Question 13 Type: MCSA After a patient undergoes surgery, the nurse notes that the analgesics prescribed are not relieving the patient’s pain. A review of the patient’s medical records reveals a history of alcohol abuse. What inferences can the nurse make? 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. Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: There is no evidence that the patient is addicted to the medication. Rationale 3: There is no evidence that the patient takes the medication at home. Rationale 4: There is no evidence that the patient has a dual diagnosis related to alcohol and drug addiction. Global Rationale: Cross-tolerance results when tolerance to one substance also results in a tolerance to another drug. The patient’s heavy use of alcohol likely has resulted in a tolerance to alcohol and, by association, to the prescribed analgesic. There is no evidence that the patient takes the medication at home, is addicted to the medication, or has a dual diagnosis related to alcohol and drug addiction. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 102
Question 14 Type: MCSA A patient involved in a minor accident reports having used “crank” an hour ago. The patient denies having used the drug before. What manifestations can the nurse anticipate occurring with this patient? 1. reports feelings of insomnia and confusion 2. shows increased strength and cognition 3. displays paranoia 4. exhibits hallucinations Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Crank is a form of methamphetamine. It will cause the patient to have insomnia and confusion. Rationale 2: The patient will not show increased strength and cognition. Rationale 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. Rationale 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. Global Rationale: Crank is a form of methamphetamine. It will cause the patient to have insomnia and feel confusion. The patient will not show increased strength and cognition. Paranoia and hallucinations might be seen in an individual who has been using crank for a long period of time but not by someone who has used it once. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 103
Question 15 Type: MCSA A patient comes into the emergency department wanting to be checked for sexual activity since she was out the other night at a rave and cannot remember what occurred. The nurse realizes that which addictive substance would cause this effect? 1. ecstasy 2. crank 3. marijuana 4. alcohol Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Crank is a stimulant and would heighten the user’s awareness. Rationale 3: Marijuana does not usually cause an individual to forget events. Rationale 4: Unless taken in high quantities over long periods of time, alcohol does not usually cause an individual to forget events. Global Rationale: 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. Crank is a stimulant and would heighten the user’s awareness. Marijuana does not usually cause an individual to forget events. Unless taken in high quantities over long periods of time, alcohol does not usually cause an individual to forget events. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 103
Question 16 Type: MCSA A patient admitted with seizures is diagnosed with a perforated nasal septum. The nurse realizes that this patient most likely has abused which substance? 1. cocaine 2. marijuana 3. alcohol 4. barbiturates Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Long-term intranasal use of cocaine is associated with a perforated nasal septum. Severe overdose of cocaine can lead to a seizure disorder. Rationale 2: Seizures and perforation of the nasal septum are not associated with marijuana. Rationale 3: Seizures and perforation of the nasal septum are not associated with alcohol. Rationale 4: Seizures and perforation of the nasal septum are not associated with barbiturate abuse. Global Rationale: Long-term intranasal use of cocaine is associated with a perforated nasal septum. Severe overdose of cocaine can lead to a seizure disorder. Seizures and perforation of the nasal septum are not associated with marijuana, alcohol, or barbiturate abuse. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 102
Question 17 Type: MCSA A teenage patient brought to the emergency department by his parents was reported to have taken 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 Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Seizure activity is not the greatest risk for this patient. Rationale 3: Signs of withdrawal are not the greatest risk for this patient. Rationale 4: Hallucinations are not the greatest risk for this patient. Global Rationale: 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. Seizure activity, signs of withdrawal, and hallucinations are not the greatest risks for this patient. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: Page Number: 102
Question 18 Type: MCSA A patient comes to the emergency department with a PCP overdose. Which intervention should the nurse anticipate will be needed? 1. Administer haloperidol (Haldol) as prescribed 2. Induce vomiting 3. Talk the patient down 4. Administer nalozone (Narcan) as prescribed Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The nurse should anticipate administering haloperidol (Haldol) as prescribed. Rationale 2: Inducing vomiting is not treatment for PCP overdose. Rationale 3: Talking the patient down is not recommended for PCP overdose. Rationale 4: Nalozone (Narcan) is not a treatment for PCP overdose. Global Rationale: PCP overdose is associated with possible hypertensive crisis, respiratory arrest, hyperthermia, and seizures. The nurse should anticipate administering haloperidol (Haldol) as prescribed. Inducing vomiting is not treatment for PCP overdose. Talking the patient down is not recommended for PCP overdose. Nalozone (Narcan) is not a treatment for PCP overdose. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: 1.A.1.Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: Page Number: 106
Question 19 Type: MCSA A patient is brought into the emergency department with dilated pupils, respiratory rate of six per minute, and seizure activity. What should the nurse prepare to administer to this patient? 1. nalozone (Narcan) 2. activated charcoal 3. ammonium chloride 4. diazepam (Valium) Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Dilated pupils, respiratory depression, and seizure activity are signs of heroin overdose. The nurse should prepare to administer nalozone (Narcan) to reverse the effects of central nervous system depression. Rationale 2: Activated charcoal is used for alcohol or barbiturate overdose. Rationale 3: Ammonium chloride is used for cocaine overdose. Rationale 4: Diazepam (Valium) is used for LSD overdose. Global Rationale: Dilated pupils, respiratory depression, and seizure activity are signs of heroin overdose. The nurse should prepare to administer nalozone (Narcan) to reverse the effects of central nervous system depression. Activated charcoal is used for alcohol or barbiturate overdose. Ammonium chloride is used for cocaine overdose. Diazepam (Valium) is used for LSD overdose. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: Page Number: 106
Question 20 Type: MCSA 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. nalozone (Narcan)
Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Thiamine (vitamin B1) is necessary to prevent the complications of chronic alcoholism such as Wernicke syndrome. Rationale 2: Diazepam (Valium) is used in the acute treatment of LSD overdose. Rationale 3: Methadone is prescribed to manage heroin cravings. Rationale 4: Nalozone (Narcan) is used to treat the effects of central nervous system depression. Global Rationale: Thiamine (vitamin B1) is necessary to prevent the complications of chronic alcoholism such as Wernicke syndrome. Diazepam (Valium) is used in the acute treatment of LSD overdose. Methadone is prescribed to manage heroin cravings. Nalozone (Narcan) is used to treat the effects of central nervous system depression. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: 12.1.3. Examine the diagnosis and treatment of obesity and malnutrition. Page Number: 105
Question 21 Type: FIB The patient has been included in a research study along with 4,205 other patients who live in the United States. Two thousand two hundred of these patients are male. Of the female patients, how many are likely to be smokers? Standard Text: Round the answer to the nearest whole number. Correct Answer: 431 Rationale: An estimated 21.5% women in the United States are current smokers. If there are 4,205 patients included in this study and 2,200 patients are male, then 2,005 patients are female; 21.5% of 2,005 is 431. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: 5.9.1. Explain the incidence, risk factors, and pathophysiology of chronic obstructive pulmonary disease. Page Number: 100
Question 22 Type: MCSA The patient has consumed 660 milligrams of caffeine during the last eight hours. The patient states that he consumes this amount of caffeine on a regular basis. After reviewing the information included in the chart provided, which patient statement is consistent with the information provided?
1. “I don’t know why but I just can’t get to sleep.” 2. “I always feel cold.” 3. “I have been so constipated.” 4. “I have no appetite.” Correct Answer: 1 Rationale 1: A caffeine intake of over 600 mg per day is considered excessive and is not recommended. Caffeine that is consumed in large quantities can cause higher total cholesterol levels and insomnia. Rationale 2: Patients who consume large quantities of caffeine are also more likely to feel warm. Rationale 3: Patients who consume large quantities of caffeine are more likely to have increased frequency of stools. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Patients who consume large quantities of caffeine are more likely to have an increased appetite. Global Rationale: A caffeine intake of over 600 mg per day is considered excessive and is not recommended. Caffeine that is consumed in large quantities can cause higher total cholesterol levels and insomnia. Patients who consume large quantities of caffeine are also more likely to feel warm, have increased frequency of stools, and have an increased appetite. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 100
Question 23 Type: MCSA The patient states she has been using an illegal drug for the last nine years. Based on the information included in the chart, which statement is most consistent with the type of illegal drug she has been abusing?
1. “My husband and I smoke our fair share of herb.” 2. “I should tell you tell that I drink quite a bit of hooch.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. “I am probably addicted to Big D.” 4. “I use the white stuff.” Correct Answer: 1 Rationale 1: Chronic long-term use of cannabis, which is also called herb, can lead to airway constriction, bronchitis, and sinusitis. The reproductive system is also affected by marijuana. It causes decreased spermatogenesis and testosterone levels in males and suppresses follicle-stimulating and luteinizing hormones in females. Rationale 2: Hootch is a term used to describe alcohol. Rationale 3: Big D is a term used to describe hallucinogens. Rationale 4: White stuff is a term used to describe heroin or morphine. Global Rationale: Chronic long-term use of cannabis, which is also called herb, can lead to airway constriction, bronchitis, and sinusitis. The reproductive system is also affected by marijuana. It causes decreased spermatogenesis and testosterone levels in males and suppresses follicle-stimulating and luteinizing hormones in females. Hootch is a term used to describe alcohol. Big D is a term used to describe hallucinogens. White stuff is a term used to describe heroin or morphine. . Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 101
Question 24 Type: MCMA The patient has been diagnosed with substance dependence. The patient has been using Bennies for the last three years. Which patient statements should the nurse attribute to substance dependence? Standard Text: Select all that apply. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 1,2,3,4 Rationale 1: Fatigue and depression are withdrawal symptoms associated with the use of amphetamines. Rationale 2: Behavior associated with substance dependence includes unsuccessful attempts to cut down on the use of the substance. Rationale 3: Fixation on obtaining more of the substance is characteristic of dependency. Rationale 4: Patients are more likely to develop tolerance to the drug and require greater quantities to get the same result. Rationale 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. Global Rationale: “Bennies” is a term used to describe amphetamines. Substance dependence can be associated with withdrawal symptoms from the substance. Fatigue and depression are withdrawal symptoms associated with the use of amphetamines. When patients are unsuccessfully attempting to cut down on their use of the substance, dependence can often be the cause. Fixation on obtaining more of the substance is characteristic of dependency. Patients are more likely to develop tolerance to the drug and require greater quantities to get the same result. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 103
Question 25 Type: MCMA The nurse is preparing material for a staff development presentation on substance abuse. Which information should the nurse include that addresses the family history of substance abuse? Standard Text: Select all that apply. 1. There is a genetic link between having an alcoholic parent and developing problems related to substance use. 2. These genetic issues are more often related to alcohol, marijuana, and tobacco use. 3. One type of genetically related alcoholism is associated with an antisocial personality disorder, early use, and an inability to stop drinking. 4. The patient has an increased likelihood of developing substance use problems when the mother of the patient is an alcoholic rather than the father. 5. Some studies indicate that adolescents who are more genetically prone to develop alcoholism were less likely to have other types of substance use problems. Correct Answer: 1, 2, 3 Rationale 1: Children of alcoholics have a greater risk for developing substance use problems. Rationale 2: These types of genetic issues lead to problems with alcohol, marijuana, and tobacco use. Rationale 3: One type of alcoholism seen mostly in the sons of alcoholic fathers is associated with an inability to abstain, early onset, and an antisocial personality. Rationale 4: One type of alcoholism seen mostly in the sons of alcoholic fathers is associated with an inability to abstain, early onset, and an antisocial personality. These types of genetic issues are typically found in male relatives. Rationale 5: Studies have shown that dopamine has been identified as the primary neurotransmitter responsible for sustaining the addictive quality of drugs and for increasing drug-seeking behavior. Global Rationale: Children of alcoholics have a greater risk for developing substance use problems. These types of genetic issues lead to problems with alcohol, marijuana, and tobacco use. One type of alcoholism seen mostly in the sons of alcoholic fathers is associated with an inability to abstain, early onset, and an antisocial personality. These types of genetic issues are typically found in male relatives. Studies have shown that dopamine has been LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
identified as the primary neurotransmitter responsible for sustaining the addictive quality of drugs and for increasing drug-seeking behavior. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: Page Number: 97-99
Question 26 Type: MCMA A patient admitted to an addiction detoxification unit has been prescribed medication to help with withdrawal symptoms. After reviewing the medication with the patient, the nurse realizes that further education is required when the patient makes which statements? Standard Text: Select all that apply. 1. “Naltrexone is an antidepressant.” 2. “The Antabuse will help me with my cravings for heroin.” 3. “The clordiazepoxide 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.” Correct Answer: 1,2 Rationale 1: Naltrexone (Vivitrol) helps diminish cravings for alcohol and opiates. It is not an antidepressant. Rationale 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. Rationale 3: Chlordiazepoxide (Librium) can be used to help with anxiety and prevent seizure activity. Rationale 4: Phenobarbital can help prevent seizure activity. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Vitamin supplements can help the patient with alcoholism because patients with alcoholism are more likely to have developed vitamin deficiencies. Global Rationale: Naltrexone (Vivitrol) helps diminish cravings for alcohol and opiates. It is not an antidepressant. 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. Chlordiazepoxide (Librium) can be used to help with anxiety and prevent seizure activity. Phenobarbital can help prevent seizure activity. Vitamin supplements can help the patient with alcoholism because patients with alcoholism are more likely to have developed vitamin deficiencies. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: Page Number: 107
Question 27 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3, 4, 5
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Completing documentation and being prepared to give report at the end of the shift does not indicate a substance abuse problem. Rationale 3: Offering to give medications to patients is consistent with a substance use problem. Rationale 4: Unorganized thinking and erratic behavior are consistent with a substance use problem. Rationale 5: The narcotic count is off while this nurse is working; this is consistent with a nurse who uses narcotics from the hospital supply. Global Rationale: Eating an excessive number of mints and wearing strong-smelling cologne can be used to mask odors of alcohol on the nurse’s breath. Offering to give medications to patients is consistent with a substance use problem. Unorganized thinking and erratic behavior are consistent with a substance use problem. The narcotic count is off while this nurse is working; this is consistent with a nurse who uses narcotics from the hospital supply. Completing documentation and being prepared to give report at the end of the shift does not indicate a substance abuse problem. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
Question 28 Type: MCMA The patient is exhibiting some addictive behaviors and has admitted to using illegal drugs. Which patient statements are consistent with addictive behaviors? Standard Text: 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.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 1, 2, 3 Rationale 1: People who are displaying addictive behaviors associated with substance use are more likely to be anxious. Rationale 2: People who are displaying addictive behaviors associated with substance use more likely to have a low tolerance for pain. Rationale 3: People who are displaying addictive behaviors associated with substance use more likely to participate in risky behaviors such as stealing. Rationale 4: People who are displaying addictive behaviors associated with substance use more likely to participate in risky behaviors such as bungee jumping without regard for social norms or their own safety. Rationale 5: People who are displaying addictive behaviors associated with substance use more likely to become angry than others who are not using substances. Global Rationale: People who are displaying addictive behaviors associated with substance use are more likely to be anxious, have a low tolerance for pain, participate in risky behaviors such as stealing and bungee jumping without regard for social norms or their own safety, and are more likely to become angry than others who are not using substances. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe common characteristics of people with substance abuse problems. MNL Learning Outcome: Page Number: 99-100
Question 29 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The patient states, “I think I am actually addicted to nicotine.” Which assessment findings are consistent with this type of addiction? Standard Text: Select all that apply. 1. The blood pressure is 182/86. 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. Correct Answer: 1, 2, 3 Rationale 1: Nicotine use results the release of norepinephrine and epinephrine, which produces vasoconstriction. Vasoconstriction will increase the patient’s blood pressure. Rationale 2: Patients who use nicotine will find that it promotes vomiting. Rationale 3: Quitting smoking is thought to be more difficult because of dopamine release, which reinforces the craving for more. Rationale 4: Due to the effects of the norepinephrine and epinephrine, the patient’s heart rate would be higher than 72 beats per minute. Rationale 5: Due to the effects of the norepinephrine and epinephrine, the patient’s respiratory rate would be greater than 14 breaths per minute. Global Rationale: Nicotine use results the release of norepinephrine and epinephrine which produces vasoconstriction. Vasoconstriction will increase the patient’s blood pressure. Patients who use nicotine will find that it promotes vomiting. Quitting smoking is thought to be more difficult because of dopamine release, which reinforces the craving for more. Due to the effects of the norepinephrine and epinephrine the patient’s heart rate and respiratory rate would both be higher than the stated levels. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 100
Question 30 Type: MCMA 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 addition teaching is required? Standard Text: 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.” Correct Answer: 1, 2 Rationale 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 B1 deficiency. Rationale 2: The patient who smokes cigarettes is more likely to develop asthma. Asthma is not necessarily associated with drinking alcohol. Rationale 3: The patient had an increased risk of developing heart problems by drinking alcohol. Rationale 4: The patient had an increased chance of developing impotence by drinking. Rationale 5: The patient’s mother had an increased risk of developing breast cancer due to her alcoholism. Global Rationale: 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 B1 deficiency. The patient who smokes cigarettes is more likely to develop asthma. Asthma is not necessarily associated with drinking alcohol. The patient had an increased risk of developing heart problems by drinking alcohol. The patient had an increased LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
chance of developing impotence by drinking. The patient’s mother had an increased risk of developing breast cancer due to her alcoholism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 101-102
Question 31 Type: MCMA The patient has been brought to the emergency department after being found by his mother at home. The patient’s blood alcohol level is currently 0.51%. Which findings are consistent with this information? Standard Text: 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!” Correct Answer: 1, 2 Rationale 1: With this blood alcohol level, the patient is likely to be in a coma. Rationale 2: The patient’s respiratory rate may be very depressed. Rationale 3: The peripheral pulses are more likely to be weak and thready due to peripheral vascular collapse, which would make it difficult for the nurse to palpate. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The patient is not likely to be talking to the nurse about the quality of his sleep. Rationale 5: The patient is not likely to be talking to the nurse about his ability to drive. Global Rationale: With this blood alcohol level, the patient is likely to be in a coma. The patient’s respiratory rate may be very depressed. The peripheral pulses are more likely to be weak and thready due to peripheral vascular collapse, which would make it difficult for the nurse to palpate. The patient is not likely to be talking to the nurse about the quality of his sleep or about his ability to drive. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 102
Question 32 Type: MCMA A patient admitted to the hospital after a motor vehicle accident frequently smokes ice and had smoked some as recently as two hours prior to the accident. Which assessment findings are consistent with this information? Standard Text: Select all that apply. 1. Apical heart rate is 112 beats per minute. 2. Preventricular 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. Correct Answer: 1, 2, 3, 4 Rationale 1: The patient will likely exhibit tachycardia. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The patient will likely exhibit dysrhythmias. Rationale 3: The patient’s appetite has been suppressed by the methamphetamine use and the patient will likely be thin. Rationale 4: Angina is a common complaint among people who use methamphetamines. Rationale 5: The patient’s blood pressure is likely to be elevated due to the vasoconstriction that is produced by this type of drug use. Global Rationale: The patient will likely exhibit tachycardia and dysrhythmias. The patient’s appetite has been suppressed by the methamphetamine use and the patient will likely be thin. Angina is a common complaint among people who use methamphetamines. The patient’s blood pressure is likely to be elevated due to the vasoconstriction that is produced by this type of drug use. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 102-103
Question 33 Type: MCMA The nurse suspects that a patient has a substance dependency. What observations did the nurse use to come to this conclusion? Standard Text: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
5. discontinues use while experiencing intrapersonal problems Correct Answer: 1, 2, 3, 4 Rationale 1: Substance dependence is demonstrated by tolerance to the drug. Rationale 2: Substance dependence is demonstrated by using the drug longer than intended. Rationale 3: Substance dependence is demonstrated by spending more time using the substance in private. Rationale 4: There is an unsuccessful persistent desire to cut down or control the substance. Rationale 5: Substance abuse manifestations include continued use despite intrapersonal problems. Global Rationale: Substance dependence is demonstrated by tolerance to the drug, using the drug longer than intended, and spending more time using the substance in private. The dependent patient will also spend more time getting, taking, and recovering from use; there is an unsuccessful persistent desire to cut down or control the substance, there is more withdrawal from family and friends, and there is continued use despite knowledge of adverse effects. Substance abuse manifestations include continued use despite intrapersonal problems, failure to fulfill major roles, and involvement in physically hazardous situations while impaired. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 97
Question 34 Type: MCMA 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? Standard Text: Select all that apply. 1. fetal CNS disturbances LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. tachycardia 3. asthma with long-term use 4. diuresis 5. hypertension Correct Answer: 1, 2, 3 Rationale 1: The use of cannabis during pregnancy can cause fetal CNS changes. Rationale 2: The use of cannabis can cause tachycardia. Rationale 3: With long-term use, cannabis can cause asthma. Rationale 4: Diuresis is not caused by cannabis, but is caused by the use of caffeine. Rationale 5: Hypertension is not caused by cannabis, but is found in cocaine users. Global Rationale: The use of cannabis during pregnancy can cause fetal CNS changes because it crosses the placental barrier; this interferes with breastfeeding. It also causes tachycardia and with long term use; can cause asthma, bronchitis; and can increase the risk of respiratory cancer. Diuresis is not caused by cannabis, but is caused by the use of caffeine. Hypertension is found in cocaine users. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Discuss risk factors associated with substance abuse. MNL Learning Outcome: Page Number: 101
Question 35 Type: SEQ A patient has overdosed on benzodiazepines and is admitted in a comatose state. What is the best order for treatment? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: Click and drag the options below to move them up or down. Choice 1. Clear airway Choice 2. Prepare to intubate Choice 3. Prepare for IV fluids Choice 4. Prepare for gastric lavage Choice 5. Institute seizure precautions Choice 6. Prepare for possible dialysis Correct Answer: 1,2,3,4,5,6 Rationale 1: With the overdosed and comatose patient, the airway is the first consideration (follows the ABCs). Rationale 2: Next, the nurse needs to prepare for intubation of the patient as this is the second priority. Rationale 3: The nurse will need to prepare for IV fluids. Rationale 4: Gastric lavage may be done to try and remove any remaining drug. Rationale 5: Seizure precautions are instituted as the patient may experience seizure activity. Rationale 6: The patient may need dialysis to remove the drug that has reached the blood. Global Rationale: With the overdosed and comatose patient, the airway is the first consideration (follows the ABCs). Next, the nurse needs to prepare for intubation of the patient as this is the second priority. The nurse will need to prepare for IV fluids. Gastric lavage may be done to try and remove any remaining drug. Seizure precautions are instituted as the patient may experience seizure activity. The patient may need dialysis to remove the drug that has reached the blood. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 106
Question 36 Type: FIB A patient withdrawing from alcohol has an order for diazepam (Valium), 10 mg every 4 hours for 4 doses, then 5 mg every 4 hours for 4 doses. The drug comes in a concentration of 5 mg/mL. The total mL that the patient will receive would be ___ . Standard Text: Fill in the blank with a numeric answer. Correct Answer: 12 mL Rationale : The drug comes in 5 mg/mL, and at 10 mg ordered, each dose is 2 mL. 2 mL × 4 doses = 8 mL. The four doses of 5 mg = 4 mL. 4 + 8 = 12. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: Page Number: 107
Question 37 Type: MCHS The nurse is reviewing the way abusive substances act on brain receptor sites. Place an “X” on the picture that represents an antagonistic effect.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: With antagonistic effects (antagonist inhibits action between physiological process), the drug interferes with release of neurotransmitter, the drug acts as a false transmitter, and the drug causes leakage of the neurotransmitter from synaptic vesicles. Agonistic action is a drug that has a specific cellular affinity and produces a predictable response. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the effects of addictive substances on physiologic, cognitive, psychologic, and social well-being. MNL Learning Outcome: Page Number: 99
Question 38 Type: MCMA The nurse is caring for a patient with chronic alcoholism. Which vitamins should the nurse expect this patient to be prescribed? Standard Text: Select all that apply. 1. thiamine (vitamin B1) 2. folic acid 3. cyanocobalamin (vitamin B12) 4. vitamin E 5. potassium chloride Correct Answer: 1, 2 Rationale 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. Rationale 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. Rationale 3: Cyanocobalamin (vitamin B12) may be important but would be found in a multivitamin. Rationale 4: Vitamin E may be important but would be found in a multivitamin. Rationale 5: Potassium chloride is incorrect as it is a mineral/electrolyte. Global Rationale: 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. The other vitamins may be important, but would be found in a multivitamin. Potassium chloride is incorrect as it is a mineral/electrolyte. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: 12.5.3. Examine the diagnosis and treatment for liver disorders. Page Number: 107
Question 39 Type: FIB A loading dose of magnesium sulfate 4g is ordered for a patient. The concentration available is 4g/250 mL to be given over 30 minutes. How many mL/hr should the nurse set the patient’s infusion pump to deliver the medication? Standard Text: Correct Answer: 500 mL/hr Rationale : 4g/30 min = X mL/h. 250mL/30 min = X mL/h. 250 mL/30 min X 2/2 = 500 mL/60 min = 500 mL/h. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: 7.7.3. Examine the diagnosis and treatment options for seizure disorders. Page Number: 107
Question 40 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is beginning the assessment of a patient with substance abuse. What should the nurse ask that demonstrates an open-ended question? Standard Text: 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? Correct Answer: 1, 2, 3 Rationale 1: Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss his or her use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than “Yes” or “No.” Rationale 2: Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss his or her use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than “Yes” or “No.” Rationale 3: Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss his or her use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than “Yes” or “No.” Rationale 4: Options 4 and 5 are closed questions and require that the patient only answer “Yes” or “No.” Rationale 5: Options 4 and 5 are closed questions and require that the patient only answer “Yes” or “No.” Global Rationale: Options 1, 2, and 3 are open-ended questions that will allow the patient to discuss his or her use of drugs/alcohol. Since they are open-ended, the patient will need to answer more than “Yes” or “No.” Options 4 and 5 are closed questions and require that the patient only answer “Yes” or “No.” Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 108
Question 41 Type: MCSA 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 Correct Answer: 1 Rationale 1: The nurse has been convicted, so the state board in his or her state will investigate and take action including censure, probation, or suspension of the nursing license. Rationale 2: An employee assistance program may be involved but will not investigate the conviction. Rationale 3: With the conviction, the court system has taken action and would be in the county, not the state. Rationale 4: The American Nurses Association will not be involved. Global Rationale: The nurse has been convicted, so the state board in his or her state will investigate and take action including censure, probation, or suspension of the nursing license. An employee assistance program may be involved but will not investigate the conviction. With the conviction, the court system has taken action and would be in the county, not the state. The American Nurses Association will not be involved. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
Question 42 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCMA The nurse 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? Standard Text: Select all that apply. 1. frequently late to work 2. incomplete charting 3. errors in patient care judgment 4. erratic behavior 5. mood swings Correct Answer: 1, 2, 3, 4 Rationale 1: Warning signs of role strain that could indicate substance abuse include frequent tardiness or absenteeism, especially before and after scheduled days off. Rationale 2: Warning signs of role strain that could indicate substance abuse include shoddy charting. Rationale 3: Warning signs of role strain that could indicate substance abuse include patient care judgment errors. Rationale 4: Warning signs of role strain that could indicate substance abuse include unorganized erratic behavior. Rationale 5: Mood swings are a characteristic of depression. Global Rationale: Warning signs of role strain that could indicate substance abuse include frequent tardiness or absenteeism, especially before and after scheduled days off, haphazard, shoddy charting, patient care judgment errors, and unorganized, erratic behavior. Mood swings are a characteristic of depression. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: 1I.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: Quality and Safety; Ethics Comportment; Commit to a generative safety culture Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Recognize the potential for substance abuse in coworkers. MNL Learning Outcome: Page Number: 114
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 43 Type: MCMA The nurse identifies the problem of imbalanced nutrition due to insufficient intake for a patient hospitalized for substance abuse. What interventions should the nurse identify as appropriate for this patient? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: Lab values should be monitored to evaluate the extent of malnourishment. Rationale 2: The dietician can help with meal planning for adequate nutrition and realistic weight gain. Rationale 3: Vitamins and dietary supplements may be ordered to prevent complications from chronic alcoholism such as Wernicke syndrome. Rationale 4: A high fat, high carbohydrate diet is not appropriate as the patient needs a balanced nutritional intake to provide for calories, proteins, vitamins, minerals, and carbohydrates. Rationale 5: The fluid intake will not be restricted as there is no physiological reason unless the patient has a comorbidity. Global Rationale: Lab values should be monitored to evaluate the extent of malnourishment. The dietician can help with meal planning for adequate nutrition and realistic weight gain. Vitamins and dietary supplements may be ordered to prevent complications from chronic alcoholism such as Wernicke syndrome. A high fat, high carbohydrate diet is not appropriate as the patient needs a balanced nutritional intake to provide for calories, proteins, vitamins, minerals, and carbohydrates. The fluid intake will not be restricted as there is no physiological reason unless the patient has a co-morbidity. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: 11.1.4. Utilize the nursing process in care of client. Page Number: 113
Question 44 Type: MCMA The nurse is determining a patient’s degree of dependence on a substance. Which screening tools should the nurse use to help with this assessment? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: These screening tools provide a nonjudgmental, brief, and easy method to determine patterns of substance abuse behaviors. The Clinical Institute Withdrawal Assessment of Alcohol, Revised and the Clinical Opiate Withdrawal Scale are assessment tools for withdrawal from alcohol and drugs and can indicate the need for pharmacologic treatment to manage withdrawal. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: 11.5.4. Utilize the nursing process in care of client. Page Number: 109
Question 45 Type: MCMA The nurse is assessing a patient for alcohol abuse. On which mental health problems should the nurse focus during this assessment? Standard Text: Select all that apply. 1. psychosis 2. depression 3. malnutrition 4. Alzheimer disease 5. cerebrovascular accident Correct Answer: 1, 2 Rationale 1: The most commonly co-occurring mental disorders in adults are alcohol abuse or alcohol dependence with depression or psychoses. Rationale 2: The most commonly co-occurring mental disorders in adults are alcohol abuse or alcohol dependence with depression or psychoses. Rationale 3: Malnutrition is not a mental health problem. Rationale 4: Alzheimer disease is not associated with alcohol abuse. It is not considered a mental health problem. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The most commonly co-occurring mental disorders in adults are alcohol abuse or alcohol dependence with depression or psychoses. Malnutrition is not a mental health problem. Alzheimer disease is not associated with alcohol abuse. It is not considered a mental health problem. 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. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Recognize the pathophysiology, manifestations, and complications of substance abuse. MNL Learning Outcome: Page Number: 97
Question 46 Type: MCMA 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? Standard Text: Select all that apply. 1. “Substance abuse is sign of weakness and boredom with life.” 2. “Alcohol reinforces the transmission of opioids in the system.” 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.” Correct Answer: 2, 3, 5 Rationale 1: There is no evidence that substance abuse is a sign of weakness and boredom with life. Rationale 2: Current data suggest that alcohol increases endogenous opioid neurotransmission and that this activation is partly responsible for its reinforcing effect. Rationale 3: The human tendency to seek pleasure and avoid stress and pain is partially responsible for substance abuse. Rationale 4: Genetic makeup and biological factors do contribute to substance abuse behaviors; however, there are other explanations. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Dopamine has been identified as the primary neurotransmitter responsible for sustaining the addictive quality of drugs and for increasing drug-seeking behavior. Global Rationale: The human tendency to seek pleasure and avoid stress and pain is partially responsible for substance abuse. Although far from definite, evidence implicates the endogenous opioid system in the development and maintenance of addictive behaviors. Current data suggest that alcohol increases endogenous opioid neurotransmission and that this activation is partly responsible for its reinforcing effect. Dopamine has been identified as the primary neurotransmitter responsible for sustaining the addictive quality of drugs and for increasing drug-seeking behavior. The reinforcing properties of drugs can create a pleasurable experience and reduce the intensity of unpleasant experiences. There is no evidence to support that substance abuse is a sign of weakness and boredom with life. Genetic makeup and biological factors do contribute to substance abuse behaviors; however, there are other explanations. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 1. Recognize the pathophysiology, manifestations, and complications of substance abuse. MNL Learning Outcome: Page Number: 97
Question 47 Type: MCMA The nurse is concerned that a patient being seen in the mental health clinic for psychosis is at risk for substance abuse. What assessment findings support this nurse’s concern? Standard Text: Select all that apply. 1. age 19 2. male gender 3. younger siblings in high school 4. mother in rehabilitation for heroin 5. recently terminated from employer Correct Answer: 1, 2, 4, 5 Rationale 1: Patients with co-occurring disorders are more likely to be unemployed younger males living in unstable conditions with more than one psychiatric diagnosis and a personality disorder. Rationale 2: Patients with co-occurring disorders are more likely to be unemployed younger males living in unstable conditions with more than one psychiatric diagnosis and a personality disorder. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: There is no evidence that having younger siblings in high school increases the risk for substance abuse. Rationale 4: Patients with co-occurring disorders are more likely to be unemployed younger males living in unstable conditions with more than one psychiatric diagnosis and a personality disorder. Rationale 5: Patients with co-occurring disorders are more likely to be unemployed younger males living in unstable conditions with more than one psychiatric diagnosis and a personality disorder. Global Rationale: Patients with co-occurring disorders are more likely to be unemployed younger males living in unstable conditions with more than one psychiatric diagnosis and a personality disorder. There is no evidence to support having younger siblings in high school increases the risk for substance abuse. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Recognize the pathophysiology, manifestations, and complications of substance abuse. MNL Learning Outcome: Page Number: 97
Question 48 Type: MCMA The nurse decides to include the CAGE questionnaire and B-DAST screening tool when assessing an adolescent admitted with panic and agitation. For which substances is this nurse most likely planning to assess in this patient? Standard Text: Select all that apply. 1. PCP 2. LSD 3. crack 4. heroin 5. alcohol Correct Answer: 1, 2, 5 Rationale 1: A manifestation of PCP overdose is agitation. Rationale 2: A manifestation of LSD overdose is panic. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: The patient is not demonstrating evidence of crack overdose. Rationale 4: The patient is not demonstrating evidence of heroin overdose. Rationale 5: Alcohol is the most commonly used and abused legal substance in the United States. Global Rationale: A manifestation of PCP overdose is agitation. A manifestation of LSD overdose is panic. The patient is not demonstrating evidence of crack or heroin overdose. Alcohol is the most commonly used and abused legal substance in the United States. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: 1.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Support interprofessional care for the patient with substance abuse problems, including diagnostic tests, emergency care for overdose, and treatment of withdrawal. MNL Learning Outcome: Page Number: 101, 106
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 7 Question 1 Type: MCSA A school bus transporting a local university’s basketball team has just crashed in the rain on the side of the road. The bus was transporting approximately 60 people. 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 Correct Answer: 1 Rationale 1: A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Rationale 2: Natural disasters are caused by acts of nature or emerging diseases. Rationale 3: Human-generated disasters are either accidental or intentional. Rationale 4: A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. Global Rationale: A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Natural disasters are caused by acts of nature or emerging diseases. Human-generated disasters are either accidental or intentional. A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the difference between an emergency and a disaster. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 119 Question 2 Type: MCSA The nurse is caring for a patient with injuries received in 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 Correct Answer: 1 Rationale 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. Rationale 2: A human-generated disaster can be either accidental or intentional. An example of a humangenerated disaster is war or biological warfare. Rationale 3: An emergency can generally be handled within the emergency management system. Rationale 4: A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Global Rationale: 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. A human-generated disaster can be either accidental or intention. An example of a human-generated disaster is war or biological warfare. An emergency can generally be handled within the emergency management system. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the difference between an emergency and a disaster. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 118 Question 3 Type: MCSA A small commuter plane lost an engine and crashed into a shopping mall. The estimated number of injured people from this accident is 500. 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 Correct Answer: 1 Rationale 1: A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. Rationale 2: A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Rationale 3: Natural disasters are caused by acts of nature or emerging diseases. Rationale 4: An intentional human-generated disaster is done with specific intent. Global Rationale: A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Natural disasters are caused by acts of nature or emerging diseases. An intentional human-generated disaster is done with specific intent. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the difference between an emergency and a disaster. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 119 Question 4 Type: MCSA A train derailed in a local community. The contents of the train caused a hazardous spill, and noxious gasses are being released into the environment. All local and surrounding fire control and Hazmat teams have been mobilized and the event is considered under control. Which type of situation should the nurse prepare for? 1. emergency 2. disaster 3. human-generated accidental disaster 4. intentional emergency Correct Answer: 1 Rationale 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. Rationale 2: A disaster would overwhelm the management systems in place. Rationale 3: Because the management systems in place were able to handle the event, this is not a disaster. Rationale 4: Intentional emergency is not a classification used for these types of event. Global Rationale: 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 rather than a disaster. A disaster would overwhelm the management systems in place. Intentional emergency is not a classification used for these types of event. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the difference between an emergency and a disaster. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 118 Question 5 Type: MCSA 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 Correct Answer: 1 Rationale 1: Radiation sickness commonly occurs with a radiological dispersion bomb or dirty bomb blast. Rationale 2: Fractured limbs and spinal injury can occur with blunt trauma. Rationale 3: Thermal burns occur with nuclear detonation. Rationale 4: Overexertion and exhaustion occur in other types of injuries, such as snowstorm-related injuries. Global Rationale: Radiation sickness commonly occurs with a radiological dispersion bomb or dirty bomb blast. Fractured limbs and spinal injury can occur with blunt trauma. Thermal burns occur with nuclear detonation. Overexertion and exhaustion occur in other types of injuries, such as snowstorm-related injuries. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 121, 124 Question 6 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA Several patients are admitted after being exposed to a substance that was released in their manufacturing plant. The patients are demonstrating flu-like symptoms, unproductive cough, and fever. These patients should be assessed for which type of exposure? 1. anthrax 2. smallpox 3. dirty bomb 4. nuclear detonation Correct Answer: 1 Rationale 1: Inhalation anthrax carries the highest mortality rate among biologic weapons. The patient initially exhibits influenza-like symptoms such as fever, nonproductive cough, headache, and malaise that advance to respiratory distress, mediastinal widening, and hemodynamic collapse in 3 to 5 days. Death may occur shortly thereafter. Untreated patients die in 2 to 3 days. Rationale 2: Smallpox spreads by direct contact or by inhalation of respiratory droplets. Symptoms include a high fever, headache, and malaise, followed by a vesicular/pustular rash appearing simultaneously on the face and extremities. Rationale 3: A dirty bomb causes radiation sickness. Rationale 4: Nuclear detonation causes thermal burns. Global Rationale: Inhalation anthrax carries the highest mortality rate among biologic weapons. The patient initially exhibits influenza-like symptoms such as fever, nonproductive cough, headache, and malaise that advance to respiratory distress, mediastinal widening, and hemodynamic collapse in 3 to 5 days. Death may occur shortly thereafter. Untreated patients die in 2 to 3 days. Smallpox spreads by direct contact or by inhalation of respiratory droplets. Symptoms include a high fever, headache, and malaise, followed by a vesicular/pustular rash appearing simultaneously on the face and extremities. A dirty bomb causes radiation sickness. Nuclear detonation causes thermal burns. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.4. Identify high risk biological pathogens' mode of transmission and symptoms. Page Number: 121 Question 7 Type: MCSA The nurse is caring for a patient who was brought into the emergency department after an explosion at a nuclear power plant. The patient is confused and keeps repeating that his skin is “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. Correct Answer: 1 Rationale 1: For victims of a nuclear detonation, comfort measures, such as psychologic support and empathy, are given. Rationale 2: The patient’s clothing would be burning his skin if he had experienced a chemical injury. Rationale 3: Evidence of gastrointestinal system involvement would be nausea, loss of appetite, diarrhea, and malaise. Rationale 4: Evidence of bone marrow damage would be nausea, fatigue, malaise, clotting disorders, and hemorrhage. Global Rationale: For victims of a nuclear detonation, comfort measures, such as psychologic support and empathy, are given. The patient’s clothing would be burning his skin if he had experienced a chemical injury. Evidence of gastrointestinal system involvement would be nausea, loss of appetite, diarrhea, and malaise. Evidence of bone marrow damage would be nausea, fatigue, malaise, clotting disorders, and hemorrhage. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.4. Identify high risk biological pathogens' mode of transmission and symptoms. Page Number: 124-125 Question 8 Type: MCSA 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.” Correct Answer: 1 Rationale 1: The bright flash of a nuclear detonation can cause temporary blindness, but vision returns in up to 30 minutes. The patient may need assistance until vision is restored. The nurse should explain that the effects of the blast will disappear with time. Rationale 2: The nurse should not say that the patient is permanently blind. Rationale 3: The nurse does not need to contact social services at this time for the patient’s temporary blindness. Rationale 4: Suggesting resources for the vision-impaired is premature, as the blindness is temporary. Global Rationale: The bright flash of a nuclear detonation can cause temporary blindness, but vision returns in up to 30 minutes. The patient may need assistance until vision is restored. The nurse should explain that the effects of the blast will disappear with time. The nurse should not say that the patient is permanently blind. The nurse does not need to contact social services at this time for the patient’s temporary blindness. Suggesting resources for the vision-impaired is premature, as the blindness is temporary. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.4. Identify high risk biological pathogens' mode of transmission and symptoms. Page Number: 124 Question 9 Type: MCSA 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. Correct Answer: 1 Rationale 1: The nurse should flush the patient’s eye with eyewash. Rationale 2: The patient should be cautioned not to rub the eye that has specks of dust or debris in it. Rationale 3: A cool compress and not a warm compress should be applied to the eye. Rationale 4: Debris lodged in the eye should be stabilized and not removed without medical attention. Global Rationale: The nurse should flush the patient’s eye with eyewash. The patient should be cautioned not to rub the eye that has specks of dust or debris in it. A cool, not warm, compress should be applied to the eye. Debris lodged in the eye should be stabilized, not removed without medical attention. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 124 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 10 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Placing the patients in the same room may or may not be appropriate. Rationale 3: The family members of the patients do not need to be assessed at this time. Rationale 4: The foods ingested during the air show may not provide enough information about the patients’ exposure. Global Rationale: 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. Placing the patients in the same room may or may not be appropriate. The family members of the patients do not need to be assessed at this time. The foods ingested during the air show may not provide enough information about the patients’ exposure. The nurse should contact public health authorities. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.4. Communicate observations or concerns related to hazards and errors to patients, families and the health care 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; 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 121 Question 11 Type: MCSA An individual arrives at the emergency department with injuries sustained in a natural gas explosion. The patient 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 Correct Answer: 1 Rationale 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. Rationale 2: An air embolism would impact the patient’s respiratory status. Rationale 3: There is no evidence to suggest the patient’s oxygen saturation level is impaired. Rationale 4: There is no evidence of confusion. Global Rationale: 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. An air embolism would impact the patient’s respiratory status. There is no evidence to suggest the patient’s oxygen saturation level is impaired. There is no evidence of confusion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 123 Question 12 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Respiratory system injuries would manifest as hemothorax, pneumothorax, or pulmonary contusion and hemorrhage. Rationale 3: Pulmonary emboli can occur with respiratory or cardiac system injuries. Rationale 4: Evidence of radiation sickness includes nausea, diarrhea, and malaise. Global Rationale: The patient who is unconscious after an explosion should be further assessed for a concussion, closed and open brain injury, stroke, spinal cord injury, or air embolism-induced injury. Respiratory system injuries would manifest as hemothorax, pneumothorax, or pulmonary contusion and hemorrhage. Pulmonary emboli can occur with respiratory or cardiac system injuries. Evidence of radiation sickness includes nausea, diarrhea, and malaise. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 123 Question 13 Type: MCMA Two school buses carrying 75 children each collide en route to an out-of-state field trip. The emergency department nurse knows that reverse triage will need to be instituted. What principles should the nurse follow when implementing reverse triage? Standard Text: Select all that apply. 1. When there is a mass casualty event with more than 100 victims, reverse triage may be instituted. 2. Reverse triage works on the principle of the greatest good for the greatest number. 3. A very basic reverse triage system is to categorize or label victims needing the most support and emergency care as red, so they can be treated first. 4. Victims most likely to survive are color-coded black, and are treated first. 5. Reverse triage works on the principle of the greatest good for the most critically ill. Correct Answer: 1,2 Rationale 1: This is a principle of reverse triage. Rationale 2: This is a principle of reverse triage. Rationale 3: This is a principle of basic triage. Rationale 4: Victims who are color-coded black are not likely to survive. Rationale 5: Basic triage works on the principle of the greatest good for the most critically ill. Global Rationale: When there is a mass casualty event with more than 100 patients, reverse triage may be instituted. Reverse triage works on the principle of the greatest good for the greatest number. Labeling victims needing the most support and emergency care as red so they can be treated first is a principle of basic triage. Victims who are color-coded black are not likely to survive. Basic triage works on the principle of the greatest good for the most critically ill. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 14 Type: MCSA A serious highway accident on a foggy night involves 22 vehicles. Several of the victims are ambulatory. The emergency personnel determine that their injuries are minor and arrange for transportation home. Why are these victims triaged first? 1. To do the greatest good for the greatest number of people 2. To remove them so they do not see the critically injured victims 3. To secure the site in case the vehicles become overheated and ignite 4. To improve traffic conditions to clear the accident site quickly Correct Answer: 1 Rationale 1: Reverse triage works on the principle of the greatest good for the greatest number of people. Rationale 2: Because these victims are ambulatory, with minor injuries, emergency personnel arrange for them to 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. Rationale 3: The purpose of reverse triage is not to secure the accident site. Rationale 4: The purpose of reverse triage is not to improve traffic conditions. Global Rationale: Reverse triage works on the principle of the greatest good for the greatest number of people. Because victims are ambulatory, with minor injuries, emergency personnel arrange for them to 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, to secure the accident site, or improve traffic conditions. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 15 Type: MCSA Emergency response personnel arrive 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. If implementing reverse triage, what should the emergency personnel do first? 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. Correct Answer: 1 Rationale 1: Reverse triage works on the principle of the greatest good for the greatest number of people. The emergency personnel should first identify one safe location for all ambulatory victims to be assessed and observed. Rationale 2: Systematically assessing the victims on the ground and assigning colors is not following the principle of reverse triage. Rationale 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. Rationale 4: Transferring victims on the ground to stretchers and sending them to local emergency departments is done after systematic assessment. Global Rationale: Reverse triage works on the principle of the greatest good for the greatest number of people. The emergency personnel should first identify one safe location for all ambulatory victims to be assessed and observed. Systematically assessing the victims on the ground and assigning colors is not following the principle of reverse triage. Entering the building to locate other victims would be done after all victims who are ambulatory or on the ground are assessed and treated. Transferring victims on the ground to stretches and sending them to local emergency departments is done after systematic assessment. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 16 Type: MCSA A victim of a plane crash exits the plane and runs to an emergency provider to tell him that his mother is trapped inside and is unable to walk out on her own. What should the emergency provider do? 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’s son that his mother 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 his mother on her feet. Correct Answer: 1 Rationale 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. Rationale 2: The emergency provider should not enter the plane to locate the trapped victim first. Rationale 3: The emergency provider should not tell the son that his mother will be fine because there is no way of knowing the extent of her injuries. Rationale 4: The emergency provider should not tell the son to go back inside the wreckage and get his mother on her feet. Global Rationale: 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. The emergency provider should not enter the plane to locate the trapped victim first. The emergency provider should not tell the son that his mother will be LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
fine because there is no way of knowing the extent of her injuries. The emergency provider should not tell the son to go back inside the wreckage and get his mother on her feet. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 17 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: The cold zone is considered the safe zone. Rationale 4: There is no green zone when working with decontamination. Global Rationale: 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. The site where a weapon was released or where LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. The cold zone is considered the safe zone. There is no green zone when working with decontamination. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 18 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 4: There is no yellow decontamination zone. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. 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. 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. There is no yellow decontamination zone. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 19 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: A gown would not be indicated at this time. Rationale 3: Gloves would not be indicated at this time. Rationale 4: Goggles would not be indicated at this time.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. A gown, gloves, and goggles would not be indicated at this time. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 126 Question 20 Type: MCSA The nurse is assessing victims of a building collapse. Ambulances are nearby and a shelter has been set up with carts, chairs, tables, and refreshments for the victims. The nurse is most likely working within which decontamination zone? 1. cold 2. warm 3. control 4. hot Correct Answer: 1 Rationale 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. Rationale 2: The warm zone is adjacent to the hot zone. This is where decontamination of victims or triage and emergency treatment take place. Rationale 3: Another name for the warm zone is the control zone. This is where decontamination of victims or triage and emergency treatment take place. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. The warm zone is adjacent to the hot zone. This is where decontamination of victims or triage and emergency treatment take place. 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. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 21 Type: MCSA 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, preparedness Correct Answer: 1 Rationale 1: Disaster management is a cyclical process comprising preparedness, mitigation, response, recovery, and evaluation. Rationale 2: The five basic stages of disaster management do not follow this sequence. Rationale 3: The five basic stages of disaster management do not follow this sequence. Rationale 4: The five basic stages of disaster management do not follow this sequence. Global Rationale: Disaster management is a cyclical process comprising preparedness, mitigation, response, recovery, and evaluation. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 119 Question 22 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The nurse does not need to consult hospital administrators when planning this program. Rationale 3: The nurse does not need to consult physicians when planning this program. Rationale 4: The nurse does not need to consult schools and day care centers when planning this program. Global Rationale: 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. The nurse does not need to consult hospital administrators, physicians, or schools and day care centers when planning this program. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 119 Question 23 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: The residents of a senior facility do not need to be concerned with turning off electrical devices. Rationale 3: The residents of a senior facility do not need to be concerned with packing food items. Rationale 4: Recreational items are not considered survival items. Global Rationale: 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, LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
sturdy shoes, warm clothing, blankets, incontinence briefs, prostheses, hearing aids, hearing aid batteries, extra wheelchair batteries, oxygen, and other assistive devices. The residents of a senior facility do not need to be concerned with turning off electrical devices or packing food items. Recreational items are not considered survival items. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 128 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The recovery aspect of disaster response, also called reconstruction, involves rebuilding and returning to some semblance of normalcy. Rationale 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. Rationale 4: The response phase involves the immediate response to the disaster. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. The recovery aspect of disaster response is also called reconstruction. The response phase involves the immediate response to the disaster. The recovery and reconstruction phase involves rebuilding and returning to some semblance of normalcy. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 120 Question 25 Type: MCMA 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? Standard Text: 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 Correct Answer: 1,3,4,5 Rationale 1: Disaster nursing competencies include risk reduction, disease prevention, and health promotion. Rationale 2: The nursing process is not considered a core competency for disaster nursing. Rationale 3: Disaster nursing competencies include policy development and planning. Rationale 4: Disaster nursing competencies include community care. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Disaster nursing competencies include ethical and legal practice. Global Rationale: Disaster nursing competencies include risk reduction, disease prevention, and health promotion; policy development and planning; community care; and ethical and legal practice. The nursing process is not considered a core competency for disaster nursing. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 118 Question 26 Type: MCSA The hospital has been notified of a subway derailment involving approximately 250 passengers. Many of the passengers are reported to be injured. For which type of situation should the emergency department manager prepare? 1. a natural disaster 2. a multiple-casualty incident 3. a mass-casualty incident 4. an accidental disaster Correct Answer: 3 Rationale 1: Natural disasters are caused by acts of nature or emerging diseases. Rationale 2: A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. Rationale 3: A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. Rationale 4: An accidental disaster is human-generated.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: A mass-casualty incident occurs quickly and suddenly and overwhelms local resources with many seriously ill or injured victims needing care. Natural disasters are caused by acts of nature or emerging diseases. A multiple-casualty event does not exceed the capacity of local resources to provide needed medical care. An accidental disaster is human-generated. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Explain the difference between an emergency and a disaster. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 119 Question 27 Type: MCSA The care area has been alerted to a possible illness associated with the tainting of a popular over-the-counter pain reliever. The nurse realizes the tainting of this product is what kind of event? 1. a nonconventional terrorist attack 2. a conventional terrorist attack 3. an accidental disaster 4. a natural disaster Correct Answer: 1 Rationale 1: Nonconventional terrorism uses chemical, biological, and nuclear means to release a toxin, contaminate a food source, or contaminate some other product. Rationale 2: This would not be classified as a conventional type of terrorist attack. Rationale 3: This would not be classified as an accidental disaster. Rationale 4: This would not be classified as a natural disaster. Global Rationale: Nonconventional terrorism uses chemical, biological, and nuclear means to release a toxin, contaminate a food source, or contaminate some other product. This would not be classified as a disaster or a conventional type of terrorist attack. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the difference between an emergency and a disaster. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 120 Question 28 Type: MCSA The emergency department nurses are noting an unusually high number of patients coming in 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. Correct Answer: 2 Rationale 1: Many people must be alerted at this time. Rationale 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. Rationale 3: Closing the emergency department would not be necessary. Rationale 4: Staffing may need to be adjusted based on the number or acuity of patients, not just a trend in symptoms. Global Rationale: 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. Closing the emergency department would not be necessary. Staffing may need to be adjusted based on the number or acuity of patients, not just a trend in symptoms. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 127 Question 29 Type: MCSA A patient comes into the clinic with the onset of itching after opening a letter received about a week ago that contained “quite a bit of white powder.” It is suspected that this patient has had an anthrax exposure. Which medication can the nurse anticipate will most likely be prescribed for this patient? 1. normal saline solution flush to the skin 2. ciprofloxacin (Cipro) 3. acetaminophen 4. Solu-Medrol Correct Answer: 2 Rationale 1: The exposure has already taken place. There is no purpose in cleaning the skin with normal saline. Rationale 2: On confirmation of anthrax exposure, prophylaxis is initiated with oral ciprofloxacin (Cipro) or doxycycline (Doxycin) for 60 to100 days. Rationale 3: Acetaminophen is used as an antipyretic and analgesic. Rationale 4: Solu-Medrol is used to manage allergic reactions and respiratory conditions. Global Rationale: On confirmation of anthrax exposure, prophylaxis is initiated with oral ciprofloxacin (Cipro) or doxycycline (Doxycin) for 60 to100 days. The exposure has already taken place. There is no purpose in cleaning the skin with normal saline. Acetaminophen is used as an antipyretic and analgesic. Solu-Medrol is used to manage allergic reactions and respiratory conditions. Cognitive Level: Applying Client Need: Safe and Effective Care Environment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.4. Identify high risk biological pathogens' mode of transmission and symptoms. Page Number: 121 Question 30 Type: MCSA A patient says to the nurse, “I’m scared about a terrorist attack because I live so close to the airport.” What should the nurse respond to the patient? 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.” Correct Answer: 3 Rationale 1: Moving because of this fear is not realistic, and the suggestion does little to assist the patient at this time. Rationale 2: The nurse should not discount the patient’s fears. Rationale 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. Rationale 4: The nurse should not compound the patient’s fears. Global Rationale: 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. The nurse should not discount the patient’s fears or compound those fears. Moving because of this fear is not realistic, and the suggestion does little to assist the patient at this time. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: V.B.2. Demonstrate effective use of strategies to reduce risk of harm to self or others LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 119 Question 31 Type: MCSA 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. to learn the organization’s disaster plan 2. to have the nurses participate in the plan for handling a disaster 3. to educate the nurses in how to recognize possible terrorists 4. to learn how the nurse will participate in mitigation Correct Answer: 4 Rationale 1: The staff should already be familiar with the organization’s disaster plan. Rationale 2: The focus of the program is prevention, not handling a disaster that has already taken place. Rationale 3: Recognition of terrorists is not the focus of the nursing team. Rationale 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. Global Rationale: 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. The staff should already be familiar with the organization’s disaster plan. The focus of the program is prevention, not handling a disaster that has already taken place. Recognition of terrorists is not the focus of the nursing team. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Quality and Safety; Practice; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 120 Question 32 Type: MCSA 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. reconstitution 3. mitigation 4. disaster reflection Correct Answer: 2 Rationale 1: Restoration is a recovery stage in which rebuilding takes place. Rationale 2: Reconstitution occurs when the life of the community returns to a “new” normal. Rationale 3: Mitigation activities focus on the prevention or reduction of the harmful effects of a disaster. Rationale 4: Disaster reflection is a recall of the events that have taken place. Global Rationale: Reconstitution occurs when the life of the community returns to a “new” normal. Restoration is a recovery stage in which rebuilding takes place. Mitigation activities focus on the prevention or reduction of the harmful effects of a disaster. Disaster reflection is a recall of the events that have taken place. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the difference between an emergency and a disaster. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 120 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 33 Type: MCSA 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 Correct Answer: 4 Rationale 1: While the provision of support is important for patients who have developed radiation sickness, it does not directly preserve life. Rationale 2: Transplantation of a heart or lung will not reduce the damage caused by the radiation exposure of a dirty bomb. Rationale 3: Transplantation of a liver will not reduce the damage caused by the radiation exposure of a dirty bomb. Rationale 4: Radiation sickness results from exposure to a dirty bomb. While this condition can be deadly, it is survivable with bone marrow transplantation. Global Rationale: Radiation sickness results from exposure to a dirty bomb. While this condition can be deadly, it is survivable with bone marrow transplantation. While the provision of support is important for patients who have developed radiation sickness, it does not directly preserve life. Transplantation of a heart, lung, or liver will not reduce the damage caused by the radiation exposure of a dirty bomb. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 123 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 34 Type: MCSA 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. Correct Answer: 1 Rationale 1: After the chemical exposure, the patient’s clothing should be removed. Rationale 2: The chemical should be flushed from the skin with copious amounts of cool running water. Rationale 3: Jewelry should be removed. Rationale 4: Contact lenses should be removed. Global Rationale: After the chemical exposure, the patient’s clothing, jewelry, and contact lenses should be removed. The chemical should then be flushed from the skin with copious amounts of cool running water. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 123 Question 35 Type: MCSA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. stress-related injuries 2. crushing injuries 3. myocardial infarctions 4. burns Correct Answer: 3 Rationale 1: Stress-related injuries would result from a situation that promotes anxiety. A snow event would not fulfill that criterion. Rationale 2: Crushing injuries would result from something falling on individuals. Snow does not meet that criterion. Rationale 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. Rationale 4: Burn injuries do not typically accompany snowfall. Global Rationale: 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. Stress-related injuries would result from a situation that promoted anxiety. Crushing injuries would result from something falling on individuals. Snow does not meet those criteria. Burn injuries will not accompany snowfall. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 123 Question 36 Type: MCSA The emergency response team is setting up an area in which to triage victims of a building blast in a major metropolitan area. Which area should the nurse identify to set up this triage location? 1. hot zone LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. warm zone 3. cold zone 4. clean zone Correct Answer: 3 Rationale 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. Rationale 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. Rationale 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. Rationale 4: None of the zones is referred to as a clean zone. Global Rationale: The cold zone is considered the safe zone. It is the area in which a more in-depth triage of victims can be performed. 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. The warm zone also serves as a location for decontamination of victims. Personal protective equipment is needed. It is not a safe location for the in-depth triage. None of the zones is referred to as a clean zone. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 37 Type: MCMA The nurse is planning the coding for a triage disaster plan. Which colors should the nurse use for this plan? Standard Text: Select all that apply. 1. white LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. red 3. yellow 4. black 5. green Correct Answer: 2,3,4,5 Rationale 1: The color white is not used in triage systems. Rationale 2: Red is one of the four basic colors used in triage systems. Red is considered critical. Rationale 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. Rationale 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. Rationale 5: Green is one of the four basic colors used in triage systems. It indicates minor injuries. Global Rationale: The four basic colors used in triage systems are red, yellow, green, and black. Red is considered critical, yellow is stable but still needs attention at a hospital, green indicates minor injuries, and black represents a victim who has died or is unlikely to survive. The color white is not used in triage systems. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 38 Type: MCSA A woman arrives at the site of a disaster, hysterically crying because she was in the building that collapsed just minutes earlier. What should the nurse do with this patient?
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1. Advise her to go home and be with her family. 2. Triage the patient and transport her to the hospital. 3. Have a nurse talk with the patient. 4. Ask psychiatric service personnel to talk with this patient. Correct Answer: 4 Rationale 1: The patient is very upset and should not be sent away without any intervention. Rationale 2: The patient escaped the building before it collapsed and experienced no injuries. Triage services need to be preserved for those who suffered injuries. Rationale 3: This patient requires the assistance of psychiatric personnel. Rationale 4: Social Services personnel or psychiatric service personnel should be available to assist the “worried well” in coping with the trauma they have just experienced, witnessed, or heard about through the media. Global Rationale: Social Services personnel or psychiatric service personnel should be available to assist the “worried well” in coping with the trauma they have just experienced, witnessed, or heard about through the media. The patient is very upset and should not be sent away without any intervention. The patient escaped the building before it collapsed and experienced no injuries. Triage services need to be preserved for those who suffered injuries. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 126 Question 39 Type: MCSA An older patient asks the nurse, “What can we do to be prepared if there’s a disaster in our community?” How should the nurse respond? 1. “There is not really much we can do to be prepared.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. “Plan to evacuate your home at a moment’s notice.” 3. “Make sure all your important papers, health information, medication information, and next-of-kin information is in one place.” 4. “Make sure you can call your family to come and pick you up if this happens.” Correct Answer: 3 Rationale 1: Planning can significantly reduce adverse outcomes in the event of a disaster. Rationale 2: Not all disasters require immediate evacuation from the home. Rationale 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. Rationale 4: Phone communication may not be possible during the initial phases of a disaster. Global Rationale: 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. Planning can significantly reduce adverse outcomes in the event of a disaster. Not all disasters require immediate evacuation from the home. Phone communication may not be possible during the initial phases of a disaster. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.2. Identify the required nursing educational competencies for responding to a mass casualty incident. Page Number: 128 Question 40 Type: MCSA A mass casualty accident has occurred. The nurse in the emergency department receives a patient who is coded red. What care should the nurse prepare to provide to this patient? 1. Send the patient home. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 3 Rationale 1: Green coding means home care would be sufficient. Rationale 2: Yellow means that the patient can be evaluated within a few hours. Rationale 3: Red means the patient needs life-saving intervention. Rationale 4: Black means the patient will most likely die from the injuries. Global Rationale: Green means home care would be sufficient. Yellow means that the patient can be evaluated within a few hours. Red means the patient needs life-saving intervention. Black means the patient will most likely die from the injuries. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 41 Type: FIB A patient with a confirmed diagnosis of anthrax is prescribed ciprofloxacin 500 mg to be administered intravenously over 60 minutes. The pharmacy provides a 1-gram vial of Cipro to the nursing unit to be diluted with 10 mL of sodium chloride. How many mL of the medication should the nurse give to the patient? Standard Text: Correct Answer: 4
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale: When the 1 gram of Cipro is reconstituted with 10 mL sodium chloride, the dilution of Cipro is 100 mg/1 mL. To achieve the ordered dose, the nurse would need to place 4 mL of solution into a standard IV piggyback solution for transfusion. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Use technologies that contribute to safety Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 121 Question 42 Type: FIB After an anthrax exposure, the healthcare provider orders doxycycline 100 mg po. The label on the bottle of doxycycline powder states it is to be reconstituted with sterile water to prepare a concentration or 0.025 g/5 mL. The nurse should prepare to administer __ mL to the patient. Standard Text: Correct Answer: 20 Rationale: When the concentration is 0.025 g/5 mL, it is necessary to change the grams to milligrams. 1000. mg = 1 g .025 × 1000 = 25 mg 25. mg/5 mL With the concentration at 25 mg/5 mL the nurse would need to administer 20 mL to comply with the order for 100 mg po. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Use technologies that contribute to safety LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 121 Question 43 Type: SEQ Utilizing the simple triage and rapid transport (START) system, in what order should the nurse prioritize the following patients? Standard Text: Click and drag the options below to move them up or down. 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/min 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. Correct Answer: 2,1,3,4 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: Triage means sorting. A very basic triage system is to categorize or label patients requiring the most support and emergency care as red. 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. Those patients who are in less critical LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. 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. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 44 Type: SEQ 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? Standard Text: Click and drag the options below to move them up or down. 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. Correct Answer: 3, 4, 2, 1 Rationale 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 are been evacuated from the exposure area. Rationale 2: Decontamination should begin as soon as patients are evacuated from the exposure area.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 4: The second step is to evacuate the victims from the exposure area, along with the healthcare providers and first responders. Global Rationale: The major activities performed for patients who have suffered a nuclear casualty 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. The victim should be evacuated from the exposure area, along with the healthcare provider and first responders. Decontamination should begin as soon as patients are evacuated from the exposure area. This may include an initial onsite decontamination followed by a second decontamination procedure at the healthcare facility. 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. Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Discuss common nursing interventions for the treatment of injuries related to biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 124 Question 45 Type: MCMA The nurse in the emergency department notes that several patients are demonstrating illness patterns that could indicate an unusual infectious disease process. What did the nurse assess that indicates a possible biological infection in these patients? Standard Text: Select all that apply. 1. Patients present with symptoms of a rare disease. 2. The disease pattern is inconsistent with the age of the patient. 3. Multiple patients are presenting with viral-like symptoms. 4. The patients are all coming from the same geographic area. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
5. Patients are all over the age of 39, indicating a smallpox exposure. Correct Answer: 1,2,4 Rationale 1: Indicators of a biological agent release include patients presenting with symptoms of a rare disease. Rationale 2: Indicators of a biological agent release include a disease pattern inconsistent with the patient’s age, such as chickenpox among adults. Rationale 3: Multiple people presenting with viral-like symptoms may merely be associated with normal exposure to a highly contagious virus. Rationale 4: An indicator of a biological agent release is increased disease incidence among people in the same geographical area. Rationale 5: If all the patients are over 39 years old, this does not necessarily indicate exposure to smallpox. The patients should be assessed for the clinical manifestations associated with smallpox. Children and young adults are equally susceptible to smallpox. Global Rationale: Healthcare providers should be alert to illness patterns that could indicate an unusual infectious disease outbreak. Indicators of a biological agent release include increased disease incidence among people in the same geographical area (e.g., people who attended the same event); a disease pattern inconsistent with patients’ age, such as chickenpox among adults; and patient presenting with symptoms of a rare disease. In these cases, the nurse should notify the chain of command including the infectious disease nurse. Multiple people presenting with viral-like symptoms may merely be associated with normal exposure to a highly contagious virus. If all the patients are over 39 years old, this does not necessarily indicate exposure to smallpox. The patients should be assessed for the clinical manifestations associated with smallpox. Children and young adults are equally susceptible to smallpox. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Describe the types of injuries and manifestations associated with biologic, chemical, or radiologic terrorism. MNL Learning Outcome: 0.2.4. Identify high risk biological pathogens' mode of transmission and symptoms. Page Number: 121 Question 46 Type: MCMA
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Emergency medical personnel are at the scene of a mass casualty incident. What information should personnel document about each victim? Standard Text: Select all that apply. 1. Name and injuries 2. Medication history 3. Interventions performed 4. Allergies 5. Name of next of kin Correct Answer: 1, 2, 3, 4 Rationale 1: Emergency medical systems (EMS) use a common triage tag state- or region-wide. The triage tag includes a sequential number and barcoded stickers for assigned categories. The triage personnel should include whatever information is available, such as the patient’s name and presenting injury or complaint. Rationale 2: Emergency medical systems (EMS) use a common triage tag state- or region-wide. The triage tag includes a sequential number and barcoded stickers for assigned categories. The triage personnel should include whatever information is available, such as medication history. Rationale 3: Emergency medical systems (EMS) use a common triage tag state- or region-wide. The triage tag includes a sequential number and barcoded stickers for assigned categories. The triage personnel should include whatever information is available, such as any interventions performed in the field. Rationale 4: Emergency medical systems (EMS) use a common triage tag state- or region-wide. The triage tag includes a sequential number and barcoded stickers for assigned categories. The triage personnel should include whatever information is available, such as allergies. Rationale 5: The next of kin is not identified or documented for each victim of a mass casualty incident. Global Rationale: Emergency medical systems (EMS) use a common triage tag state- or region-wide. The triage tag includes a sequential number and barcoded stickers for assigned categories. The triage personnel should include whatever information is available, such as the patient’s name, presenting injury or complaint, any interventions performed in the field, and allergy and medication history if possible. The next of kin is not identified or documented for each victim of a mass casualty incident. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 126 Question 47 Type: MCSA The triage nurse is tagging victims of a train derailment. One patient has a sucking chest wound, BP 90/50, respirations 32, and is alert and able to respond to questions. Utilizing the identified chart, which colored tag should the nurse assign to the patient?
1. red, immediate threat to life 2. yellow, requiring medical attention but no threat of loss of life 3. green, ambulatory with minor injuries 4. black, not expected to survive Correct Answer: 1 Rationale 1: Patients who are critically injured and require immediate intervention should be tagged red (immediate threat to life). These patients need the most support and emergency care. This would include patients with a respiratory rate above 30. Rationale 2: This patient has life-threatening injuries. Rationale 3: This patient is not ambulatory and has life-threatening injuries. Rationale 4: With the appropriate interventions, this patient can be expected to live. Global Rationale: Patients who are critically injured and require immediate intervention should be tagged red (immediate threat to life). These patients need the most support and emergency care. This would include patients with a respiratory rate above 30. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 48 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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, preimpact mobilization, and evacuation if appropriate. Rationale 3: The response phase involves the immediate response to the effects of the disaster. Rationale 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. Global Rationale: 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. 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
appropriate. The response phase involves the immediate response to the effects of the disaster. 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. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify federal, state, local, and voluntary resources that provide and support assistance with disaster preparedness, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 119 Question 49 Type: MCSA A train made up of railroad cars filled with toxic chemicals and a full school bus with 90 children on board collide in a populated area. A huge explosion occurs and a fire develops in a nearby factory. Which approach to care should be used to care for these victims?
1. emergency; use conventional triage 2. emergency; evacuate all ambulatory patients first 3. disaster; employ reverse triage 4. disaster; evacuate critically injured patients first Correct Answer: 3 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Conventional triage is limited to normal circumstances or when there are only a few victims. In conventional triage, patients requiring the most support are transported first. Rationale 2: This is a mass-casualty event. It is a disaster. Rationale 3: A mass-casualty event with more than 100 victims requires the institution of reverse triage. Reverse triage works on the principle of the greatest good for the greatest number Rationale 4: The least injured and most ambulatory patients should be transported first. Global Rationale: A mass-casualty event with more than 100 victims is a disaster requiring the institution of reverse triage. Reverse triage works on the principle of the greatest good for the greatest number. Conventional triage is limited to normal circumstances or when there are only a few victims. In conventional triage, patients requiring the most support are transported first. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe accepted triage principles used to manage multiple or mass casualty incidents and disasters. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 50 Type: MCHS A patient exposed to smallpox would present with a vesicular/pustular rash over which areas of the body? Place an “X” over the areas where the rash would initially present.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Smallpox spreads by direct contact or by inhalation of respiratory droplets. Symptoms include a high fever, headache, and malaise followed by a vesicular/pustular rash appearing simultaneously on the face and extremities. Once the lesions break open and spread large amounts of the virus into the mouth and throat, people are highly contagious and should be placed in negative-pressure rooms. Anyone exposed to the patient should be vaccinated and monitored closely. Vaccination up to 4 days after exposure and before a rash appears provides almost complete protection. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.4. Identify high risk biological pathogens' mode of transmission and symptoms. Page Number: 121 Question 51 Type: MCHS The nurse is sent to the scene of a radioactive explosion and instructed to do in-depth triage of the patients. Place an “X” in the zone where the nurse should perform this task.
Correct Answer: Rationale: The cold zone is considered the safe zone. It is adjacent to the warm zone and is the area where a more in-depth victim triage would occur. Survivors may find shelter in this area, and the command and control vehicles would be found here. The site 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 (PPE) may enter this zone. The warm zone, or control zone, is adjacent to the hot zone. This area is where decontamination of victims or triage and emergency treatment take place.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The cold zone is considered the safe zone. It is adjacent to the warm zone and is the area where a more in-depth victim triage would occur. Survivors may find shelter in this area, and the command and control vehicles would be found here. The site 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 (PPE) may enter this zone. The warm zone, or control zone, is adjacent to the hot zone. This area is where decontamination of victims or triage and emergency treatment take place. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Recognize situations requiring the need for patient isolation or patient decontamination. MNL Learning Outcome: 0.2.3. Examine emergency response plans of care, triage, and site specific disaster zones. Page Number: 125 Question 52 Type: MCMA 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? Standard Text: 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 who can help the victims Correct Answer: 2, 5 Rationale 1: The NRF does not supply specific information about caring for victims of emergencies or disasters. Rationale 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 human-generated disasters. Rationale 3: The NRF does not supply statistics about disasters. Rationale 4: The NRF does not supply specific information about caring for victims of emergencies or disasters.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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 human-generated disasters. Global Rationale: 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 human-generated disasters. The NRF does not supply statistics about disasters or specific information about caring for victims of emergencies or disasters. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify federal, state, local, and voluntary resources that provide and support assistance with disaster preparedness, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 119 Question 53 Type: MCMA 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? Standard Text: 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 Correct Answer: 2, 3, 4, 5 Rationale 1: Knowing the number of families who live in the community will not help with planning for the victims of this disaster. Rationale 2: Hospitals must be constantly aware of the number of beds available. Rationale 3: Hospitals must be constantly aware of staffing. Rationale 4: Hospitals must be constantly aware of equipment and medications on hand. Rationale 5: Hospitals must be constantly aware of which patients may be discharged. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Hospitals must be constantly aware of the number of beds available, which patients may be discharged, staffing, equipment, other resources, and their overall ability to manage casualties quickly. Knowing the number of families who live in the community will not help with planning for the victims of this disaster. Cognitive Level: Application Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Identify federal, state, local, and voluntary resources that provide and support assistance with disaster preparedness, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 120 Question 54 Type: MCMA 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? Standard Text: 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 Correct Answer: 2, 3, 5 Rationale 1: Blood pooling in extremities leads to thrombus formation. Rationale 2: In response to stress, the immune response is suppressed, leading to the onset of infections. Rationale 3: In response to stress, the basal metabolic rate changes, which alters protein, carbohydrate, and lipid metabolism. Rationale 4: Paralysis of gastrointestinal tract function affects elimination. Rationale 5: In response to stress, the basal metabolic rate changes, altering protein, carbohydrate, and lipid metabolism.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: In response to stress, the basal metabolic rate changes, altering protein, carbohydrate, and lipid metabolism. The immune response is suppressed, leading to the onset of infections. Blood pooling in extremities leads to thrombus formation. Paralysis of gastrointestinal tract function affects elimination. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 127 Question 55 Type: MCMA 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? Standard Text: 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. Correct Answer: 3, 4 Rationale 1: Fresh foods should be avoided because of the risk of contamination and subsequent infection. Rationale 2: Fresh foods should be avoided because of the risk of contamination and subsequent infection. Rationale 3: Bottled water should be ready so the patient can avoid drinking water of questionable purity. Rationale 4: Processed or canned foods are safest for this population. Rationale 5: Bottled water should be provided so that water of questionable purity can be avoided. Global Rationale: Patients who are immunocompromised pose special problems for the healthcare community, especially if access to health care is unavailable due to a disaster situation. Bottled water should be ready so the patient can avoid drinking water of questionable purity. Bone marrow and stem cell transplant patients are instructed not to eat fresh fruits and vegetables due to the risk of contamination and subsequent infection. It is LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
safest for this population of patients to consume processed or canned foods if they can be heated to the proper temperatures. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 129 Question 56 Type: MCMA 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? Standard Text: 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 Correct Answer: 2, 5 Rationale 1: The child with asthma will most likely not need additional support at this time. Rationale 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. Rationale 3: The patient with a pacemaker most likely will not need emergency support at this time. Rationale 4: The patient with multiple sclerosis most likely will not need emergency support at this time. Rationale 5: The patient who requires continuous oxygen will need immediate support because the oxygen concentrator needs electricity to run. Global Rationale: One role of the nurse in a disaster is to provide emergency services with consideration of victims’ abilities, deficits, culture, language, or special needs. The patient needing continuous oxygen and the patient with sleep apnea will need immediate care and support in a power outage. The other patients have no identified needs impacted by the loss of electricity. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of the nurse in disaster preparedness, mitigation, response, and recovery. MNL Learning Outcome: 0.2.1. Explain the four phases of emergency response and the nurse's responsibility during each phase. Page Number: 127
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 8 Question 1 Type: MCSA A female patient tells the nurse that she is 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 Correct Answer: 1 Rationale 1: The best way for this patient to avoid illness is to maintain a healthy weight and activity level. Rationale 2: While nutrition is a significant factor, it is not necessary to avoid carbohydrates. Rationale 3: Daily monitoring of blood glucose levels is not indicated for this patient. Rationale 4: It is important to take action to prevent disease and not wait for the disease to manifest. Global Rationale: The best way for this patient to avoid illness is to maintain a healthy weight and activity level. While nutrition is a significant factor, it is not necessary to avoid carbohydrates. Daily monitoring of blood glucose levels is not indicated for this patient. It is important to take action to prevent disease and not wait for the disease to manifest. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 10.5.2. Differentiate the risk factors and manifestations for diabetes. Page Number: 145
Question 2 Type: MCSA 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?” Correct Answer: 1 Rationale 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. Rationale 2: It is premature to suggest refraining from having children until the genetic study is completed. Rationale 3: It is premature to suggest adoption until the genetic study is completed. Rationale 4: Questioning whether a specific disease is genetic in origin may be helpful, but may not allay the patient’s concerns about other diseases. Global Rationale: 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. It is premature to suggest adoption or refraining from having children until the genetic study is completed. Questioning whether a specific disease is genetic in origin may be helpful, but may not allay the patient’s concerns about other diseases. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: Page Number: 137
Question 3 Type: MCSA 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 for a complete genetic analysis. 4. Refer to a geneticist for diagnosis. Correct Answer: 1 Rationale 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. Rationale 2: Conducting a health promotion assessment will not provide information regarding the patient’s risk for passing on genetic illnesses to future children. Rationale 3: Scheduling a complete genetic analysis is not the first action a nurse should take take to address a patient’s concern about transmitting genetic illnesses to children. Rationale 4: Referring the patient to a geneticist is not the first action a nurse should take to address a patient’s concern about transmitting genetic illnesses to children. Global Rationale: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
being referred to a geneticist for diagnosis. Conducting a health promotion assessment will not provide information regarding the patient’s risk for passing on genetic illnesses to future children. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: Page Number: 146
Question 4 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Ingesting a diet high in protein and carbohydrates is not going to reduce the patient’s risk for developing the disease. Rationale 3: Maximizing exercise is not going to reduce the patient’s risk for developing the disease. Rationale 4: Counseling the patient on abstaining from having children is not going to improve the patient’s risk for the disease. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Ingesting a diet high in protein and carbohydrates is not going to reduce the patient’s risk for developing the disease. Maximizing exercise is not going to reduce the patient’s risk for developing the disease. Counseling the patient on abstaining from having children is not going to improve the patient’s risk for the disease. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: 11.12.1. Explain the incidence, risk factors, and pathophysiology of colorectal cancer. Page Number: 145
Question 5 Type: MCSA 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 Correct Answer: 1 Rationale 1: A polymorphism is a change in DNA sequence that has been identified in more than 1% of the population and is, thus, more commonly observed than a mutation. Polymorphisms differ from mutations in that they are observed more frequently in the general population than mutations. Rationale 2: A mutation is a change in DNA sequence that has been identified in less than 1% of the population.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Global Rationale: A polymorphism is a change in DNA sequence that has been identified in more than 1% of the population and is, thus, more commonly observed than a mutation. Polymorphisms differ from mutations in that they are observed more frequently in the general population than mutations. A mutation is a change in DNA sequence that has been identified in less than 1% of the population. 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. 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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 140
Question 6 Type: MCSA A patient has been told that her unborn child will most likely have Down syndrome. The nurse realizes this diagnosis is consistent with which genetic finding? 1. trisomy 2. monosomy 3. translocation 4. deletions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: Monosomy refers to the presence of only one chromosome instead of the normal pair of chromosomes. Rationale 3: Translocation (chromosomal reshuffling) occurs when a segment of a chromosome transfers or moves and attaches itself to another chromosome. Rationale 4: Structural rearrangements of chromosomes may result from deletions or loss of a chromosome segment or piece. Global Rationale: 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. Monosomy refers to the presence of only one chromosome instead of the normal pair of chromosomes. Translocation (chromosomal reshuffling) occurs when a segment of a chromosome transfers or moves and attaches itself to another chromosome. Structural rearrangements of chromosomes may result from deletions or loss of a chromosome segment or piece. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 138
Question 7 Type: MCSA A nurse is planning to teach the parents of a child with cystic fibrosis about the disorder. Which statement should the nurse include in this explanation?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. “While all people carry the gene CFTR, which is responsible for cystic fibrosis, those who develop the disease have a mutation in that gene.” 2. “A small percentage of the general population carries the gene for cystic fibrosis. If two carriers have children, then 25% of those children will develop the disease.” 3. “One in four people carry the gene for cystic fibrosis. If two carriers have children, then 25% of those children will develop the disease.” 4. “Some people carry the gene for cystic fibrosis. Of those carriers, one in four will develop the disease.” Correct Answer: 1 Rationale 1: Every individual carries the gene cystic fibrosis transference regulator (CTFR). Those who develop the disease have a mutation in that gene. Rationale 2: Every individual carries the gene cystic fibrosis transference regulator. Rationale 3: Every individual carries the gene cystic fibrosis transference regulator. Rationale 4: Every individual carries the gene cystic fibrosis transference regulator. Those who develop the disease have a mutation in that gene. Global Rationale: Every individual carries the gene cystic fibrosis transference regulator. Those who develop the disease have a mutation in that gene. The other answer choices are all incorrect as they indicate that only a few carry the gene for cystic fibrosis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 139
Question 8 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient tells the nurse that many of her 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. Correct Answer: 1 Rationale 1: All humans have essentially the same 20,000 to 25,000 genes; it is the mutation or polymorphism in the gene that predisposes some individuals for disease, not translocation nor the gene itself. Rationale 2: The patient may or may not develop anemia. Rationale 3: The patient may or may not die from anemia. Rationale 4: Translocation does not predispose some individuals for disease. Global Rationale: All humans have essentially the same 20,000 to 25,000 genes; it is the mutation or polymorphism in the gene that predisposes some individuals for disease, not translocation nor the gene itself. The patient may or may not develop or die from anemia. Translocation does not predispose some individuals for disease. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: 14.1.1. Explain the incidence, causes, and pathophysiology of the different types of anemias. Page Number: 140
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 9 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Nurses should encourage open discussions and the expression of fears and concerns. When supporting a the 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. Rationale 2: The nurse should not suggest that the patient terminate the pregnancy. Rationale 3: The nurse should not tell the patient that the baby will have challenges that will need to be met by a young person. Rationale 4: Stating that all life is precious is judgmental and should not be stated by the nurse. Global Rationale: Nurses should encourage open discussions and the expression of fears and concerns. When supporting a the 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. The nurse should not suggest that the patient terminate the pregnancy nor tell the patient that the baby will have challenges that will need to be met by a young person. Stating that all life is precious is judgmental and should not be stated by the nurse. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 148
Question 10 Type: MCSA 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.” Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: The 23rd pair, the sex chromosomes, determines an individual’s gender. Rationale 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. Global Rationale: A basic understanding of the cell, DNA, cell division, and chromosomes is important for young families receiving genetic counseling. The cell nucleus contains about six 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. The first 22 pairs of chromosomes are alike in males and females. The 23rd pair, the sex chromosomes, determines an individual’s gender. A female has LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 138
Question 11 Type: MCSA At the conclusion of genetic testing, a patient learns that he has 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.” Correct Answer: 1 Rationale 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. Rationale 2: The nurse has no way of knowing whether the patient is going to need cardiac bypass surgery or not. Rationale 3: The nurse should not encourage the patient to enjoy life as much as possible now since this might lead to high-risk behaviors. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The nurse should not minimize the importance of the genetic testing results. Global Rationale: 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. The nurse has no way of knowing whether the patient is going to need cardiac bypass surgery or not. The nurse should not encourage the patient to enjoy life as much as possible now since this might lead to high-risk behaviors. The nurse should not minimize the importance of the genetic testing results. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.B.15. Communicate care provided and needed at each transition in 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 145
Question 12 Type: MCSA A patient planning to be married tells the nurse that she has a strong family history of Huntington chorea but does not plan to let her fiancé know. 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 he is not aware of the disease.” 3. “Are you afraid that he will not want to marry you if he knows?” 4. “There are worse disease processes than Huntington chorea.” Correct Answer: 1 Rationale 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 she does not want her fiancé to be aware of the genetic illness. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Agreeing that the fiancé should not be made aware would be an inappropriate response for the nurse to make. Rationale 3: Suggesting that the fiancé would not want to marry the patient if he was aware of the genetic disease is also an inappropriate response for the nurse to make. Rationale 4: The nurse should not make a judgment statement by saying that there are worse disease processes than Huntington chorea. Global Rationale: 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 she does not want her fiancé to be aware of the genetic illness. Agreeing that the fiancé should not be made aware would be an inappropriate response for the nurse to make. Suggesting that the fiancé would not want to marry the patient if he was aware of the genetic disease is also an inappropriate response for the nurse to make. The nurse should not make a judgment statement by saying that there are worse disease processes than Huntington chorea.” Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.7. Explore ethical and legal implications of patient-centered 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: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 145
Question 13 Type: MCSA A patient planning to have genetic testing prior to having children tells the nurse that she 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 doctor will most likely use the results when planning care and treatment for other patients with the same genetic disorder.”
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: The nurse should explain that the results of genetic testing are confidential and that the written permission to have access to the results will be needed by the patient. Rationale 2: Insurance companies will not need the results of the tests before paying for the tests. Rationale 3: The results will be confidential and not accessible by anyone who reviews the patient’s medical record. Rationale 4: The patient’s physician cannot use the test results when planning care and treatment for other patients with the same genetic disorder. Global Rationale: The nurse should explain that the results of genetic testing are confidential and that the written permission to have access to the results will be needed by the patient. Insurance companies will not need the results of the tests before paying for the tests. The results will be confidential and not accessible by anyone who reviews the patient’s medical record. The patient’s physician cannot use the test results when planning care and treatment for other patients with the same genetic disorder. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: I.A.7. Explore ethical and legal implications of patient-centered 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: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 145
Question 14 Type: MCSA Through testing, a patient learns of a genetic disease that he has inherited from his parents, yet none of his other siblings have inherited the same disease. The patient tells the nurse that he has always believed his parents “didn’t want him” and now he has proof. 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 he has ever discussed his thoughts and fears with his parents.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. Encourage the patient to talk with his siblings about the illness and ask them for help now before he has manifestations of the disease. 4. Remind the patient that genetic testing is inconclusive, and there is a great chance that the results are wrong. Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not suggest that the patient confront his parents with his thoughts and feelings. Rationale 3: The nurse should also not suggest that the patient discuss the test results with his siblings in order to elicit their help and support before the disease manifests. Rationale 4: Genetic testing is not inconclusive. This would be an inappropriate suggestion to make to the patient. Global Rationale: 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. The nurse should not suggest that the patient confront his parents with his thoughts and feelings. The nurse should also not suggest that the patient discuss the test results with his siblings in order to elicit their help and support before the disease manifests. Genetic testing is not inconclusive. This would be an inappropriate suggestion to make to the patient. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 148
Question 15 Type: MCSA A patient learning that her newborn baby has a genetic disorder tells the nurse that it was because a stranger gave her baby the “evil eye.” What should this information suggest to the nurse? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 she permits strangers 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. Correct Answer: 1 Rationale 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. Rationale 2: This information does not suggest that the patient needs psychiatric counseling or that the patient is not going to be a good mother. Rationale 3: This information does not suggest that the patient is not going to be a good mother. Rationale 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. Global Rationale: 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. This information does not suggest that the patient needs psychiatric counseling or that the patient is not going to be a good mother. 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.
Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 148 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 1: The patient should be advised to have a predispositional test to detect the presence of the genetic mutation that causes nonpolyposis colorectal cancer. Rationale 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. Rationale 3: In this case, genetic testing is indicated. Rationale 4: Therapy would be started only if the cancer were present. Global Rationale: The patient should be advised to have a predispositional test to detect the presence of the genetic mutation that causes nonpolyposis colorectal cancer. 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. In this case, genetic testing is indicated. Therapy would only be started if the cancer were present.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Identify the significance of recent advances in human genetics and the effect on healthcare delivery. MNL Learning Outcome: 11.12.1. Explain the incidence, risk factors, and pathophysiology of colorectal cancer. Page Number: 144
Question 17 Type: MCSA Through genetic testing, a patient learns that he has 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. Correct Answer: 1 Rationale 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. Rationale 2: Inheriting the E2 allele does not indicate that a person is more likely to develop Alzheimer disease. Rationale 3: The apolipoprotein E gene is not a predictor for contracting malaria. Rationale 4: The apolipoprotein E gene is not a predictor for developing colorectal cancer. Global Rationale: The apolipoprotein E gene provides instructions to make a protein that combines with fats in the body to form molecules called lipoproteins which 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 does not indicate that a person is more likely to develop Alzheimer disease. The apolipoprotein E gene is not a predictor for contracting malaria or developing colorectal cancer. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify the significance of recent advances in human genetics and the effect on healthcare delivery. MNL Learning Outcome: 7.8.1. Explain the incidence, causes, risk factors, and pathophysiology of Alzheimer disease. Page Number: 140
Question 18 Type: MCSA 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 Correct Answer: 1 Rationale 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 their response to drugs and the environment, thus making medical treatment and pharmacologic management more individualized. Rationale 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. Rationale 3: The specific sequence of nucleotides is referred to as the individual’s genotype. Rationale 4: Translocation occurs when a segment of a chromosome transfers or moves and attaches itself to another chromosome.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Biological markers are easily tracked, stable segments of DNA. Information gained from biological markers will provide information on how subtle differences in humans impact their response to drugs and the environment; thus making medical treatment and pharmacologic management more individualized. 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. The specific sequence of nucleotides is referred to as the individual’s genotype. Translocation occurs when a segment of a chromosome transfers or moves and attaches itself to another chromosome. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify the significance of recent advances in human genetics and the effect on healthcare delivery. MNL Learning Outcome: Page Number: 140
Question 19 Type: MCSA A patient is having difficulty achieving adequate anticoagulation with prescribed doses of warfarin. The nurse realizes that what might 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 Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: There might not be another anticoagulant available for the patient. Rationale 3: Reviewing the patient’s diet might provide some information regarding dietary reasons for the unsuccessful anticoagulation of the patient. Rationale 4: An analysis of the patient’s lifestyle will not help determine why the patient has not been achieved successful anticoagulation. Global Rationale: 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. There might not be another anticoagulant available for the patient. Reviewing the patient’s diet might provide some information regarding dietary reasons for the unsuccessful anticoagulation of the patient. An analysis of the patient’s lifestyle will not help determine why the patient has not been achieved successful anticoagulation. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify the significance of recent advances in human genetics and the effect on healthcare delivery. MNL Learning Outcome: Page Number: 144
Question 20 Type: MCSA A patient tells the nurse that her mother has type 2 diabetes and heart problems. The nurse realizes that this information: 1. means that the patient will probably not change her health habits. 2. can help predict the patient’s future health problems. 3. helps predict the future health of the patient’s children. 4. means that the patient keeps in touch with her parents. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2 Rationale 1: There is no evidence that the patient would not change any health habits. Rationale 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. Rationale 3: Although the family health history is significant, it will not provide a direct prediction for the patient’s children and is not the best answer. Rationale 4: Information to determine the relationship between the patient and her family is not given. Global Rationale: 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. There is no evidence that the patient would not change any health habits. Although the family health history is significant it will not provide a direct prediction for the patient’s children and is not the best answer. Information to determine the relationship between the patient and her family is not given. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: 10.5.2. Differentiate the risk factors and manifestations for diabetes. Page Number: 146
Question 21 Type: MCSA The physician has ordered chromosomal analysis for a newborn baby. Which test does the nurse realize will most likely be performed with this baby? 1. karyotype LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. newborn screen 3. carrier testing 4. preimplantation genetic diagnosis Correct Answer: 1 Rationale 1: The karyotype provides an analysis of the number and structure of the chromosomes. Rationale 2: Newborn screening is performed shortly after birth. It seeks to identify inborn errors of metabolism. Rationale 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 X-linked pattern of inheritance. Rationale 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. Global Rationale: The karyotype provides an analysis of the number and structure of the chromosomes. Newborn screening is performed shortly after birth. It seeks to identify inborn errors of metabolism. 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 X-linked pattern of inheritance. 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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: Page Number: 144
Question 22 Type: MCSA A 42-year-old pregnant patient asks the nurse if the baby will be born with Down syndrome because of a chromosomal abnormality. What chromosomal abnormality does the nurse know this to be? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 4 Rationale 1: The abnormality being described is not 23 pairs of chromosomes. Rationale 2: The abnormality being described is not 26 pairs of chromosomes. Rationale 3: The abnormality being described is not one that has a missing member of a chromosome pair. Rationale 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. Global Rationale: The abnormality being described is not 23 pairs of chromosomes, 26 pairs of chromosomes, or one with a missing member of a chromosome pair. A zygote that is trisomic, or one that has three chromosomes instead of the usual two, 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.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 138
Question 23 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient tells the nurse that her husband has chronic myelogenous leukemia, and she is concerned that their 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 husband 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.” Correct Answer: 1 Rationale 1: The chromosome translocation that is responsible for chronic myelogenous leukemia occurs in somatic cells, not germ cells, and therefore is not inheritable. Rationale 2: It is not appropriate to agree with the patient at this time. This may increase her level of concern needlessly. Rationale 3: Offering advice that is not in the best interest of the patient and family is not considered therapeutic communication. Rationale 4: Offering advice that is not in the best interest of the patient and family is not considered therapeutic communication. Global Rationale: The chromosome translocation that is responsible for chronic myelogenous leukemia occurs in somatic cells, not germ cells, and therefore is not inheritable. All other responses are offering advice, which is not in the best interest of the patient and her family and is not considered therapeutic communication. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 139
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 24 Type: MCSA A male patient has a history of a genetic disorder and is concerned that this same disorder will be passed to his 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. Correct Answer: 2 Rationale 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 of her children. An affected male will not pass the metabolism DNA mutation to any of his children. Rationale 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 of her children. An affected male will not pass the metabolism DNA mutation to any of his children. Rationale 3: It is inappropriate for the nurse to recommend that the patient not have children. This recommendation steps beyond the scope of practice. Rationale 4: Inherited disorders exist beyond those involving chromosomes 13, 18, and 21. Global Rationale: 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 of her children. An affected male will not pass the metabolism DNA mutation to any of his children. It is inappropriate for the nurse to recommend the patient not have children. This recommendation steps beyond the scope of practice. Inherited disorders exist beyond those involving chromosomes 13, 18, and 21. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 139
Question 25 Type: MCSA 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. Correct Answer: 4 Rationale 1: If only one parent were affected, the child would not be born with the disorder but simply would be a carrier as well. Rationale 2: If only one parent were affected, the child would not be born with the disorder but simply would be a carrier as well. Rationale 3: There is no evidence that the father is not the biological father. Rationale 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, wild-type, 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. Global Rationale: 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, wild-type, 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. If only one parent was affected, the child would not be born with the LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
disorder but simply would be a carrier as well. There is no evidence to support the fact the father is not the biological father. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 140
Question 26 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Penetrance is the probability that a gene will be expressed phenotypically. Rationale 3: X-linked conditions are recessive in nature. Rationale 4: Multifactorial conditions occur as a result of genetic variations and lifestyle and environmental influences that work together. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: When there is no previous history of a condition, including even subtle signs and symptoms of the disease in any other immediate or distant family member, the disease may be caused by a spontaneous new mutation. This is called de novo. Penetrance is the probability that a gene will be expressed phenotypically. Xlinked conditions are recessive in nature. Multifactorial conditions occur as a result of genetic variations and lifestyle and environmental influences that work together. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 143
Question 27 Type: MCSA Upon the completion of genetic testing, a patient is happy to learn that she has a negative test result. The nurse then explains to the patient that 1. she will never experience a genetically-caused disease. 2. any children she has will be free from genetic diseases. 3. her children might develop disease from genetic misplacement of chromosomes. 4. this is no guarantee that she will not develop the disease. Correct Answer: 4 Rationale 1: A negative test result cannot guarantee that the disease or condition might not develop in the future. Rationale 2: The patient’s children may experience random chromosomal abnormalities that are seen in the rest of the population. Rationale 3: This is not necessarily true. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Global Rationale: 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, which are seen in the rest of the population. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 145
Question 28 Type: MCSA A patient and her future husband completed genetic testing through a laboratory that they found on the Internet. The patient is upset because the results determined that 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 husband won’t want to get married now?” 4. “I wouldn’t worry about those results.” Correct Answer: 1 Rationale 1: A positive screening genetic test result indicates an increased risk or probability but must always be confirmed by diagnostic testing. Rationale 2: The nurse is offering advice. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: This statement may be offensive to the patient. Rationale 4: The nurse should not tell the patient and her husband that the testing is not valuable. Global Rationale: A positive screening genetic test result indicates an increased risk or probability but must always be confirmed by diagnostic testing. The other nursing responses are offering advice, which is not considered therapeutic communication. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 144
Question 29 Type: MCSA A patient tells the nurse that her teenaged son, who has a congenital abnormality, is demonstrating increasing anger and animosity toward her and her husband. The nurse realizes that the son might be 1. behaving 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. Correct Answer: 3 Rationale 1: Normal teens do not have to manage the implications associated with the occurrence of a congenital abnormality. Rationale 2: The patient is not exhibiting behavior consistent with confusion. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: The individual who has inherited an altered disease-producing gene may foster deep resentment toward the parent who carries the altered gene. Rationale 4: There is no evidence that these behaviors are related to disease process. There is no information provided to support this assumption. Global Rationale: The individual who has inherited an altered disease-producing gene may foster deep resentment toward the parent who carries the altered gene. There is no evidence that these behaviors are related to disease process. Normal teens do not have to manage the implications associated with the occurrence of a congenital abnormality. The patient is not exhibiting behavior consistent with confusion. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 145
Question 30 Type: MCSA At the conclusion of a genetic counseling session, a family member says to the nurse, “There’s got to be something that you aren’t telling us.” The nurse realizes that this individual is 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. Correct Answer: 4 Rationale 1: Feelings of guilt are not manifested in the demeanor demonstrated by the patient. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 3: Feelings of anger are not manifested in the demeanor demonstrated by the patient. Rationale 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. Global Rationale: 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. Feelings of guilt and anger are not manifested in the demeanor demonstrated by the patient. 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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 148
Question 31 Type: MCSA A baby with Down syndrome has been born to a mother who refuses to allow any family members to visit her or the newborn. What should the nurse realize this patient is demonstrating? 1. postpartum depression 2. denial LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. anxiety and guilt 4. poor bonding Correct Answer: 3 Rationale 1: Postpartum depression is not an immediate response. Rationale 2: There is no evidence that the mother is in denial. Rationale 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. Rationale 4: There is no evidence to suggest that the mother is not bonding well with the infant. Global Rationale: 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 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. Guilt and shame are very common as a patient deals with the loss of the expectation and dream of a healthy child. There is no evidence to suggest that the mother is in denial or has poor bonding with the infant. Postpartum depression is not an immediate response. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 148 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 32 Type: MCSA A patient is upset to hear the nurse say that the results of genetic testing revealed wild-type genes. The nurse should explains that this type of gene is 1. normal. 2. abnormal with limitations. 3. defective. 4. unexpected. Correct Answer: 1 Rationale 1: A normal or unaltered form of a gene is known as wild-type. Rationale 2: Wild-type genes are normal, not abnormal with limitations. Rationale 3: Wild-type genes are normal, not defective. Rationale 4: Wild-type genes are normal, not unexpected. Global Rationale: A normal or unaltered form of a gene is known as wild-type. Wild-type genes are not abnormal with limitations, defective, or unexpected. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 140
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 33 Type: MCSA A patient who is pregnant reports a family history of cystic fibrosis and asks about the risks for transmission to her child. What concepts 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. Correct Answer: 3 Rationale 1: Autosomal recessive disorders such as cystic fibrosis are transmitted equally between male and female children. Rationale 2: The disorder may appear to skip a generation. Rationale 3: Autosomal recessive disorders such as cystic fibrosis are transmitted equally between male and female children. Rationale 4: The parents of this disorder may be carriers but not affected. Global Rationale: Autosomal recessive disorders such as cystic fibrosis are transmitted equally between male and female children. The disorder may appear to skip a generation. The parents of this disorder may be carriers but not affected. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 141 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 34 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: There is no evidence of a manifestation. Newborn screening is often routine. Rationale 3: The test results indicate the baby does not have a genetic disorder. Rationale 4: There is no way to predict the baby’s future health status. Global Rationale: 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. There is no evidence of a manifestation. Newborn screening is often routine. The test results indicate the baby does not have a genetic disorder. There is no way to predict the baby’s future health status. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: Page Number: 144 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 35 Type: FIB Four hundred twenty-two people are involved in a research study regarding warfarin use. Twenty-three are African American, fourteen are Asian, and the rest are Caucasian. Based on previous research, calculate how many of the Caucasian patients may metabolize warfarin at a slower rate due to a polymorphism on the cytochrome P450 CYP2C9 gene. __ _ Standard Text: Correct Answer: 77 Rationale: Three hundred eighty-five of the 422 research participants are Caucasian. Twenty percent of Caucasians have a polymorphism on the cytochrome P450 CYP2C9 gene and consequently metabolize warfarin more slowly and take longer to achieve therapeutic dosing. Twenty percent of 385 patients is 77 people. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 144
Question 36 Type: SEQ A patient scheduled for a genetic evaluation has questions regarding the visit. Rank the steps in the order that they should most likely occur. Standard Text: Click and drag the options below to move them up or down. Choice 1. The geneticist examines the patient. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Choice 2. The patient is scheduled for diagnostic tests. Choice 3. The patient constructs a 3-generation pedigree. Choice 4. The geneticist discusses the findings with the patient and makes recommendations. Choice 5. The genetic clinical nurse interviews the patient. Correct Answer: 3,5,1,2,4 Rationale 1: The third step is for the geneticist to examine the patient. Rationale 2: The fourth step is for the patient to be scheduled for diagnostic tests. Rationale 3: The first step is for the nurse and patient to construct a 3-generation pedigree. Rationale 4: The fifth step is when the geneticist discusses the findings with the patient and makes specific recommendations. Rationale 5: The second step is for the genetic clinical nurse to interview the patient. Global Rationale: The patient should be prepared to give as exact a family history as possible so that a detailed three-generation pedigree can be constructed. During the appointment, a genetic clinical nurse, genetic counselor, and/or a physician will perform an initial interview with the patient. A geneticist will examine the patient in order to establish an accurate diagnosis. Tests may be ordered. After the exam and the completion of any applicable testing, the geneticist and/or genetic counselor will discuss the findings with the patient and make recommendations. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 146
Question 37 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA A 29-year-old patient whose mother died from an unspecified cancer at the age of 33 has the following diagnostic test results. What would be appropriate for this patient?
1. The patient is scheduled for a prostate exam. 2. The patient is scheduled for a colonoscopy. 3. The patient is scheduled for a mammogram. 4. The patient is scheduled for an ovarian cancer screening examination. Correct Answer: 2 Rationale 1: A prostate exam is not indicated for this patient. Rationale 2: This patient should be scheduled for a colonoscopy at least every 2 years beginning at age 25. This is important for this patient because the patient may have a positive family history and mutations in the MLH1/MSH2 gene, which increase the risk for hereditary nonpolyposis colorectal cancer. Rationale 3: A mammogram is not indicated for this patient. Rationale 4: Patients with breast cancer should be screened for ovarian cancer because they are closely related genetically. Global Rationale: This patient should be scheduled for a colonoscopy at least every 2 years beginning at age 25. This is important for this patient because the patient may have a positive family history and mutations in the MLH1/MSH2 gene, which increase the risk for hereditary nonpolyposis colorectal cancer. Prostate exam and mammogram are not indicated for this patient. Patients with breast cancer should be screened for ovarian cancer because they are closely related genetically. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Identify the significance of recent advances in human genetics and the effect on healthcare delivery. MNL Learning Outcome: 11.12.3. Examine the diagnosis and treatment of colorectal cancer. Page Number: 145
Question 38 Type: MCSA While reviewing a male patient’s history in the chart provided, the nurse becomes concerned. The patient states, “I haven’t been to see a physician in years, and it’s time for me to get a thorough check-up.” Based on the nurse’s understanding of genetically related diseases, which diagnostic screening examination may be ordered for this patient?
1. a mammogram 2. a prostate exam 3. a colonoscopy 4. a cardiovascular assessment Correct Answer: 4 Rationale 1: This patient does not necessarily have an increased risk of breast cancer because the patient’s mother was diagnosed with breast cancer after the age of 50. Rationale 2: The patient does not have an increased risk of prostate cancer because the patient’s uncle was diagnosed with prostate cancer after the age of 60. Rationale 3: The patient does not have an increased risk of developing colon cancer because the patient’s sister was diagnosed with colon cancer after the age of 50.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: This patient should receive a cardiovascular assessment. The patient has an increased risk of being diagnosed with a cardiovascular disease because the patient has two family members that were diagnosed with cardiovascular disorders that developed early, when compared to other people. Global Rationale: This patient should receive a cardiovascular assessment. The patient has an increased risk of being diagnosed with a cardiovascular disease because the patient has two family members that were diagnosed with cardiovascular disorders that developed early, when compared to other people. This patient does not necessarily have an increased risk of breast cancer because the patient’s mother was diagnosed with breast cancer after the age of 50. The patient does not have an increased risk of prostate cancer because the patient’s uncle was diagnosed with prostate cancer after the age of 60. The patient does not have an increased risk of developing colon cancer because the patient’s sister was diagnosed with colon cancer after the age of 50. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify the significance of recent advances in human genetics and the effect on healthcare delivery. MNL Learning Outcome: 6.4.2. Differentiate the risk factors and diagnostic tests for cardiac perfusion disorders. Page Number: 147
Question 39 Type: MCMA The parents of a newborn diagnosed with cri du chat syndrome request information about this disorder. What statements by the nurse are appropriate? Standard Text: 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.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
5. “Your baby has the low-set ears and mewing cry that is associated with this syndrome.” Correct Answer: 1, 2, 4, 5 Rationale 1: A chromosomal alteration that includes a missing or additional whole chromosome or segment of a chromosome is an unbalanced rearrangement. Rationale 2: An unbalanced rearrangement can result in missing genes, confusing directions from the genes, or too much gene product. Rationale 3: Translocation between chromosomes 9 and 22 is responsible for trisomy 21. Rationale 4: Cri du chat syndrome results from a large deletion on the short arm of chromosome 5. Rationale 5: Patients with cri du chat have mental retardation, crying that sounds like a cat mewing, and low-set ears. Global Rationale: A chromosomal alteration that includes a missing or additional whole chromosome or segment of a chromosome is an unbalanced rearrangement. An unbalanced rearrangement can result in missing genes, confusing directions from the genes, or too much gene product. Cri du chat syndrome results from a large deletion on the short arm of chromosome 5. Patients with cri du chat have mental retardation, crying that sounds like a cat mewing, and low-set ears. Translocation between chromosomes 9 and 22 is responsible for trisomy 21. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 139
Question 40 Type: MCMA The nurse working in a geneticist’s office is reviewing information about human cells with a patient. Which patient statements indicate that an adequate amount of learning has occurred? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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.” Correct Answer: 1, 3 Rationale 1: Every human cell has 23 pairs of chromosomes. There are 46 chromosomes in each cell. Rationale 2: Chromosomes are numbered according to size, largest to smallest. Chromosome 1 is largest and chromosome 46 is smallest. Rationale 3: Each human cell contains organelles such as mitochondria. Rationale 4: The 23rd pair of chromosomes determines the person’s gender. Rationale 5: Human cells function very differently based on their location. Global Rationale: Every human cell has 23 pairs of chromosomes. There are 46 chromosomes in each cell. Chromosomes are numbered according to size, largest to smallest. Chromosome 1 is largest and chromosome 46 is smallest. Each human cell contains organelles such as mitochondria. The 23rd pair of chromosomes determines the person’s gender. Human cells function very differently based on their location. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 137 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 41 Type: MCMA The nurse is reviewing the process of mitosis and meiosis with a patient receiving care in a fertility clinic. Which patient statements are examples of scenarios that involve mitotic cell division? Standard Text: Select all that apply. 1. “Sperm cells use mitosis to divide.” 2. “The patient has a healing wound on the coccyx.” 3. “The patient has acute bronchitis.” 4. “A fetus grows using mitosis.” 5. “The patient has acute gastritis.” Correct Answer: 2, 3, 4, 5 Rationale 1: Sperm cells use meiosis to divide. Rationale 2: Mitosis is the process of making new cells in bodily tissue. Cell division through mitosis heals wounds on skin surfaces. Rationale 3: The lining of the respiratory tract is replaced through mitosis. Rationale 4: A fetus grows through mitotic cell division. Rationale 5: The lining of the gastrointestinal tract is replaced by mitosis. Global Rationale: Mitosis is the process of making new cells in bodily tissue. Cell division through mitosis heals wounds on skin surfaces. The lining of the gastrointestinal tract is replaced by mitosis. A fetus grows through mitotic cell division. The lining of the respiratory tract is replaced through mitosis. Sperm cells use meiosis to divide. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 138
Question 42 Type: MCMA During a visit to a geneticist’s practice a patient with blue eyes asks the nurse to explain eye color, adding that his mother had blue eyes and his father had brown eyes. What should the nurse include in this explanation? Standard Text: 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.” Correct Answer: 2, 3, 4, 5 Rationale 1: This patient has a blue-eyed mother and a brown-eyed father, so the patient has two different forms of the gene responsible for his eye color. The patient’s alleles are heterozygous. Rationale 2: The patient’s alleles are heterozygous. Rationale 3: The patient’s blue eyes are the result of an expressed gene. An expressed gene impacts the patient’s outward experience. Rationale 4: Alleles are versions or forms of a gene. The patient’s eye color is part of his phenotype. Rationale 5: The phenotype is the patient’s entire physical, biochemical, and physiologic makeup and is influenced by genetic and environmental factors. Global Rationale: This patient has a blue-eyed mother and a brown-eyed father, so the patient has two different forms of the gene responsible for his eye color. The patient’s alleles are heterozygous. The patient’s blue eyes are the result of an expressed gene. An expressed gene impacts the patient’s outward experience. Alleles are versions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
or forms of a gene. The patient’s eye color is part of his phenotype. The phenotype is the patient’s entire physical, biochemical, and physiologic makeup and is influenced by genetic and environmental factors. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: Page Number: 139
Question 43 Type: MCMA The parents learn that their newborn has the CFTR gene located on chromosome 7. During counseling, what should the parents be told about the ways that this genetic alteration may be expressed as the child grows? Standard Text: 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. Correct Answer: 1, 2, 5 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 3: The CFTR gene does not necessarily increase the patient’s risk for developing breast cancer. Rationale 4: The CFTR gene does not necessarily increase the patient’s risk for developing Alzheimer disease. Rationale 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. Global Rationale: 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. The patient with severe cystic fibrosis may be placed on a lung transplant list. The child may experience a mild form of cystic fibrosis. The CFTR gene does not necessarily increase the patient’s risk for developing breast cancer or Alzheimer disease. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 139
Question 44 Type: MCMA The nurse at the geneticist’s office is caring for a 22-year-old patient who might have a mitochondrial mutation. Which patient statements are most consistent with this information? Standard Text: Select all that apply. 1. “My dad was unable to hear normally after the age of 15.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 2, 3, 5 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 5: The patient’s development of ataxia and hypotonia is concerning for the nurse to learn about because this can be associated with mitochondrial mutations. Global Rationale: 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. 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. The patient’s development of ataxia and hypotonia is concerning for the nurse to learn about because this can be associated with mitochondrial mutations. 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. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 139
Question 45 Type: MCMA 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 statements made by a parent indicate that further education is required? Standard Text: 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.” Correct Answer: 1, 4 Rationale 1: Genetic alterations of the X chromosome are referred to as X-linked recessive or X-linked dominant conditions. Rationale 2: This is a Mendelian condition because it follows Mendel’s laws of inheritance. Rationale 3: The parents denied having any clinical manifestations associated with the condition, so they are most likely carriers of the condition.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 5: These types of conditions are monogenic because they affect one single gene. Global Rationale: Genetic alterations of the X chromosome are referred to as X-linked recessive or X-linked dominant conditions. Autosomal recessive conditions are the result of an alteration of any of the 22 non-sex chromosomes. 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. This is a Mendelian condition because it follows Mendel’s laws of inheritance. The parents denied having any clinical manifestations associated with the condition so they are most likely carriers of the condition. These types of conditions are monogenic because they affect one single gene. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 140
Question 46 Type: MCMA A married couple has two children at home who have been diagnosed with the same autosomal dominant condition. The nurse is interviewing the couple after they become pregnant with their third child. Based on the nurse’s understanding of related psychosocial issues, which statements by the mother may be expected? Standard Text: 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.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 1,2,3,4 Rationale 1: The parents of a child with a genetically transmitted disease may feel guilty. Rationale 2: Some children may feel angry toward the parent who carries the altered gene. Rationale 3: The parent or parent may feel angry or depressed. Rationale 4: A child with a late-onset disease may be more likely to engage in risky and less socially acceptable behaviors. Rationale 5: Both males and females are equally affected with an autosomal dominant genetic disorder. Global Rationale: The parents of a child with a genetically transmitted disease may feel guilty. Some children may feel angry toward the parent who carries the altered gene. The parent or parents may feel angry or depressed. A child with a late-onset disease may be more likely to engage in risky and less socially acceptable behaviors. Both males and females are equally affected with an autosomal dominant genetic disorder. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 145
Question 47 Type: MCMA The nurse 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? Standard Text: Select all that apply. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1, 2, 4, 5 Rationale 1: Basic interventions that meet the standards of genetic nursing include evaluating care provided to patients. Rationale 2: Basic interventions that meet the standards of genetic nursing include identifying patients’ needs for referrals. Rationale 3: The nurse should advocate for the patient based upon sound information and decisions. This does not include advocating for pregnancy terminations. Rationale 4: Basic interventions that meet the standards of genetic nursing include performing accurate and thorough physical assessments. Rationale 5: Basic interventions that meet the standards of genetic nursing include completing genetic-focused family histories with patients. Global Rationale: Basic interventions that meet the standards of genetic nursing include evaluating care provided to patients, identifying patients’ needs for referrals, performing accurate and thorough physical assessments, and completing genetic-focused family histories with patients. The nurse should advocate for the patient based upon sound information and decisions. This does not include advocating for pregnancy terminations. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Discuss the role of genetic concepts in health promotion and health maintenance. MNL Learning Outcome: Page Number: 137
Question 48 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is preparing information for a group of parents as part of genetic counseling. What basic principles of inheritance should the nurse include in this presentation? Standard Text: 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 Rationale 1: The basic underlying principles of inheritance that nurses can apply to inheritance risk assessment and teaching include that all genes are paired. Rationale 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. Rationale 3: Both parents’ genes are transmitted to offspring. Rationale 4: The father’s genes are not used to fill in genetic deficits in offspring. Rationale 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. Global Rationale: The basic underlying principles of inheritance that nurses can apply to inheritance risk assessment and teaching include: (1) all genes are paired, (2) only one gene of each pair is transmitted (passed on) to an offspring, and (3) one copy of each gene in the offspring comes from the mother and the other copy comes from the father. Both parents’ genes are transmitted to offspring. The father’s genes are not used to fill in genetic deficits in offspring. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Apply knowledge of the principles of genetic transmission and risk factors for genetic disorders. MNL Learning Outcome: Page Number: 140 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 49 Type: MCMA A patient pregnant with her first child is in need of genetic testing. The health plan will cover the testing to an extent. What should the nurse encourage the patient to consider before making a decision about the testing? Standard Text: 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 Rationale 1: Depending upon the results, family members may resent the patient for having a baby with a genetic disorder. Rationale 2: Depending upon the results, there might not be a treatment available for the disorder. Rationale 3: Termination of pregnancy is not something that should be discussed at this time. Rationale 4: The patient may or may not be able to care for the baby depending upon the genetic disorder. Rationale 5: Since the health plan does provide genetic testing coverage, the plan will have information about the testing. Global Rationale: Depending upon the results, family members may resent the patient for having a baby with a genetic disorder. Depending upon the results, there might not be a treatment available for the disorder. Termination of pregnancy is not something that should be discussed at this time. The patient may or may not be able to care for the baby depending upon the genetic disorder. Since the health plan does provide genetic testing coverage, the plan will have information about the testing. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 144-148
Question 50 Type: MCMA 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? Standard Text: 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 Correct Answer: 1, 2, 4, 5 Rationale 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. Rationale 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. Rationale 3: The nurse should help the patient with problem solving and not suggest termination of the pregnancy. Rationale 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. Rationale 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. Global Rationale: 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. Actions to reduce stress and anxiety help with the problem of anxiety. Assisting to think through the process to increase optimism helps with the problem of powerlessness. Asking about a spiritual advisor helps with the problem of spiritual distress. The nurse should help the patient with problem solving and not suggest termination of the pregnancy. Cognitive Level: Applying Client Need: Psychosocial Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain the implications of genetic advances on the role of nurses with particular attention to spiritual, cultural, ethical, legal, and social issues. MNL Learning Outcome: Page Number: 146
Question 51 Type: MCMA 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? Standard Text: Select all that apply. 1. Infertility 2. Seizure disorder 3. Menopause at age 32 4. Neighbor committed suicide 5. Cousin addicted to heroin Correct Answer: 1, 2, 3 Rationale 1: Indications for a referral to a genetic specialist include infertility. Rationale 2: Indications for a referral to a genetic specialist include seizure disorder. Rationale 3: Indications for a referral to a genetic specialist include premature ovarian failure as might be seen with early menopause. Rationale 4: A neighbor’s suicide is not an indication for a genetic specialist. Rationale 5: A cousin’s drug addiction is not an indication for a genetic specialist. Global Rationale: Indications for a referral to a genetic specialist include infertility, seizure disorder, and premature ovarian failure as might be seen with early menopause. A neighbor’s suicide and a cousin’s drug addiction are not indications for a genetic specialist. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Describe the significance of delivering genetic education and counseling follow-up in a professional manner. MNL Learning Outcome: Page Number: 147
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 9 Question 1 Type: MCSA 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 the pain response to surgery. Correct Answer: 1 Rationale 1: Each person’s pain tolerance is different and will need to be assessed on an individual basis. Rationale 2: Everyone does not have the same pain threshold. Rationale 3: Everyone perceives pain at a different intensity. Rationale 4: Different people have a different pain response to surgery. Global Rationale: Each person’s pain tolerance is different and will need to be assessed on an individual basis. Everyone does not have the same pain threshold or perceive pain at the same intensity. Different people have a different pain response to surgery. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the neurophysiology of pain. MNL Learning Outcome: Page Number: 151 Question 2 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 1: Mechanical causes of pain include spasm, compression, or extreme muscle stretch or contraction. A muscle tear creates pain from a mechanical source. Rationale 2: A burn involves pain from a thermal source. Rationale 3: Frostbite involves pain from a thermal source. Rationale 4: Myocardial infarction involves pain from a chemical source. Global Rationale: There are three types of painful stimuli: mechanical, chemical, and thermal. Mechanical causes of pain include spasm, compression, or extreme muscle stretch or contraction. A muscle tear creates pain from a mechanical source. Myocardial infarction involves pain from a chemical source. Burn and frostbite involve pain from a thermal source. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the neurophysiology of pain. MNL Learning Outcome: Page Number: 154 Question 3 Type: MCSA The nurse is using the neuromatrix theory when determining a patient’s pain. What should the nurse consider when assessing a patient’s pain? 1. cultural and genetic factors LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. specificity 3. pattern 4. previous sensitization Correct Answer: 1 Rationale 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 stressregulation systems, all contribute to the pain experience for the individual. Rationale 2: Specificity theories describe nerve impulses of varying intensity terminating in pain centers in the forebrain. Rationale 3: Pattern theories describe nerve impulses of varying intensity terminating in pain centers in the forebrain. Rationale 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. Global Rationale: 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, and culture, innate pain modulation systems, and components of stress-regulation systems, all contribute to the pain experience for the individual. Specificity and pattern theories describe nerve impulses of varying intensity terminating in pain centers in the forebrain. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the neurophysiology of pain. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 153 Question 4 Type: MCSA A patient tells the nurse that he has had deep, burning muscle pain for most of his adult life. What does this information tell the nurse about how the patient’s pain is being transmitted in the body? 1. C fibers 2. A-delta fibers 3. endorphins 4. dynorphins Correct Answer: 1 Rationale 1: The pain from deep body structures, such as muscles and viscera, is primarily transmitted by C fibers, producing diffuse burning or aching sensations. Rationale 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. Rationale 3: Endorphins are endogenous opioids that block the transmission of painful impulses. Rationale 4: Dynorphins are endogenous opioids that block the transmission of painful impulses. Global Rationale: The pain from deep body structures, such as muscles and viscera, is primarily transmitted by C fibers, producing diffuse burning or aching sensations. 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. Endorphins and dynorphins are endogenous opioids that block the transmission of painful impulses. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the neurophysiology of pain. MNL Learning Outcome: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 155 Question 5 Type: MCSA A patient asks the nurse why he felt pain prior to a myocardial infarction primarily in his left arm. 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.” Correct Answer: 1 Rationale 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. Rationale 2: Cardiac pain is explainable. Rationale 3: Physical activity did not trigger the pain. Rationale 4: Psychogenic pain occurs in the absence of a diagnosed physiological cause or event. Global Rationale: 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. Cardiac pain is explainable. Physical activity did not trigger the pain. Psychogenic pain occurs in the absence of a diagnosed physiological cause or event. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: 6.4.1. Explain the incidence and pathophysiology for cardiac perfusion disorders. Page Number: 155 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 6 Type: MCSA 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. Correct Answer: 1 Rationale 1: The patient might not exhibit signs of pain such as elevations in vital signs, grimacing, writhing, or moaning. Rationale 2: There may not be an identified physiologic cause. Rationale 3: Chronic pain may persist for longer than 2 months. Rationale 4: There is no indication that chronic pain is less severe than acute pain, although in some instances it may be more diffuse. Global Rationale: The patient might not exhibit signs of pain such as elevations in vital signs, grimacing, writhing, or moaning. Chronic pain may persist for longer than 2 months and may not have an identified physiologic cause. There is no indication that chronic pain is less severe than acute pain, although in some instances it may be more diffuse. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: Page Number: 156 Question 7 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The neuropathic pain associated with amputation, phantom limb pain, may not begin immediately and may become a chronic problem. Rationale 3: Complex regional pain syndrome is a chronic exaggerated response to a painful stimulus. Rationale 4: Degenerative joint disease is chronic; the accompanying joint pain is also chronic. Global Rationale: 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. The neuropathic pain associated with amputation, phantom limb pain, may not begin immediately and may become a chronic problem. Complex regional pain syndrome is a chronic exaggerated response to a painful stimulus. Degenerative joint disease is chronic; the accompanying joint pain is also chronic. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom, pain. MNL Learning Outcome: Page Number: 155 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 8 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Reducing the sympathetic pain response would be an appropriate acute pain management goal. Rationale 3: Being completely pain free might be an unattainable goal for a patient with chronic pain. Rationale 4: Improving patient outcomes would be an appropriate acute pain management goal. Global Rationale: 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. Reducing the sympathetic pain response and improving patient outcomes would be appropriate acute pain management goals. Being completely pain free might be an unattainable goal for a patient with chronic pain. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom, pain. MNL Learning Outcome: Page Number: 156 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 9 Type: MCSA A patient scheduled for knee surgery tells the nurse, “I know I won’t feel as much pain with this knee surgery as I did with the other one when I was 20 years younger.” 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.” Correct Answer: 1 Rationale 1: Pain tolerance decreases with aging, perhaps related to the prevalence of chronic pain in this population. Rationale 2: The nurse should not agree that the patient will have less pain because this may not occur. Rationale 3: The amount of pain may or may not be impacted by the use of newer technology. Rationale 4: The pain response does not diminish with age. Global Rationale: Pain tolerance decreases with aging, perhaps related to the prevalence of chronic pain in this population. The nurse should not agree that the patient will have less pain because this may not occur. The amount of pain may or may not be impacted by the use of newer technology. The pain response does not diminish with age. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: 8.3.1. Examine the diagnosis and treatment of degenerative disorders. Page Number: 158 Question 10 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA A female patient tells the nurse that at times the pain she has is so severe that she cannot move or 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 Correct Answer: 1 Rationale 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. Rationale 2: Alcohol may raise pain tolerance. Rationale 3: Medications may raise pain tolerance. Rationale 4: Sleep and rest may raise pain tolerance. Global Rationale: 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. Medications, alcohol, sleep, and rest may raise pain tolerance. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: Page Number: 158 Question 11 Type: MCSA A patient diagnosed with depression tells the nurse that his pain has been “unrelenting” over the last several weeks. What should the nurse consider as contributing to this patient’s amount of pain? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 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. Rationale 2: The nurse has no way of knowing if the patient’s pain medication is not controlling the pain. Rationale 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. Rationale 4: The nurse cannot make the assumption that the patient is exaggerating the amount of pain. Global Rationale: 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. The nurse has no way of knowing if the patient’s pain medication is not controlling the pain. There is also no way of knowing if the medication used to treat the patient’s depression is interfering with the control of pain. The nurse cannot make the assumption that the patient is exaggerating the amount of pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: Page Number: 159 Question 12 Type: MCSA A patient tells the nurse that she is unable to sleep through the night because of leg pain. What will the nurse most likely assess in this patient? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. an increase in pain 2. a decrease in pain 3. a decrease in anxiety 4. an increase in concentration Correct Answer: 1 Rationale 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. Rationale 2: There will not be a decrease in pain. Rationale 3: Anxiety may increase the perception of pain, and pain may cause more anxiety. Rationale 4: The patient in pain often has difficulty concentrating. Global Rationale: 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. There will not be a decrease in pain. Anxiety may increase the perception of pain and pain may cause more anxiety. The patient in pain often has difficulty concentrating. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: Page Number: 159 Question 13 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 1: Anticipating a patient’s pain will ensure a more manageable pain experience than will waiting until the patient complains of pain. Rationale 2: Pain management needs to be implemented before the patient describes specific postoperative pain. Rationale 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. Rationale 4: Pain management needs to be implemented before the patient “sleeps off” anesthesia. Global Rationale: Anticipating a patient’s pain will ensure a more manageable pain experience than will waiting until the patient complains of pain. Pain management needs to be implemented before the patient describes specific postoperative pain or “sleeps off” anesthesia. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 163 Question 14 Type: MCSA 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?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 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. Rationale 2: The nerves will not regenerate, so surgery will not need to be repeated. Rationale 3: Pain medication may or may not be needed after the surgery. Rationale 4: Not all surgeries to sever nerves to control pain result in paraplegia. Global Rationale: 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. The nerves will not regenerate, so surgery will not need to be repeated. Pain medication may or may not be needed after the surgery. Not all surgeries to sever nerves to control pain result in paraplegia. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 7.6.3. Examine the diagnosis and treatment of spinal cord disorders. Page Number: 166 Question 15 Type: MCSA A patient with chronic orthopedic pain is considering the use of a transcutaneous electrical nerve stimulator to reduce the pain. What advantages of using this device should the nurse review with the patient? 1. avoiding the adverse effects of pain medication LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. low cost 3. can be used by all patients 4. can relieve all types of pain Correct Answer: 1 Rationale 1: A transcutaneous electrical nerve stimulator has the advantages of avoidance of adverse drug effects, patient control, and good interaction with other therapies. Rationale 2: Disadvantages of this device are the cost and the need for expert training. Rationale 3: This device is not effective at relieving pain for all patients. Patients with pacemakers should not use this device. Rationale 4: This device is not effective at relieving all types of pain. Global Rationale: A transcutaneous electrical nerve stimulator has the advantages of avoidance of adverse drug effects, patient control, and good interaction with other therapies. Disadvantages of this device are the cost and the need for expert training. This device is not effective at relieving all types of pain or for all patients. Patients with pacemakers should not use this device. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 8.3.3. Examine the diagnosis and treatment of degenerative disorders. Page Number: 167 Question 16 Type: MCSA A patient is watching a comedy on the television and has not requested pain medication for over 6 hours. The nurse realizes that the patient is utilizing what as a form of pain control? 1. distraction 2. meditation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. guided imagery 4. biofeedback Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. 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. 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. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 8.3.3. Examine the diagnosis and treatment of degenerative disorders. Page Number: 168
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 17 Type: MCSA 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 Correct Answer: 1 Rationale 1: Patients receiving narcotics are at risk for constipation. Increasing fiber in the diet will help to reduce this effect. Rationale 2: Increasing vitamin D is not specifically related to the effects of a narcotic medication. Rationale 3: Increasing protein is not specifically related to the effects of a narcotic medication. Rationale 4: Increasing carbohydrates is not specifically related to the effects of a narcotic medication. Global Rationale: Patients receiving narcotics are at risk for constipation. Increasing fiber in the diet will help to reduce this effect. Increasing vitamin D, protein, or carbohydrates is not specifically related to the effects of a narcotic medication. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 11.8.3. Examine the diagnosis and treatment for disorders of intestinal motility. Page Number: 164 Question 18 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is planning to administer a pain medication to a patient who is 2 hours postoperative following bowel resection surgery. The patient has four standing orders for pain medication. Which medication should the nurse consider providing to the patient at this time? 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 Correct Answer: 1 Rationale 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. Rationale 2: The medication that is administered intramuscularly is not typically recommended for moderate-tosevere pain that will require more than one dose. Rationale 3: A prn medication administered 2 hours after a major surgery would not be the most effective. Rationale 4: An oral medication administered 2 hours after a major surgery would not be the most effective. Global Rationale: 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. An oral medication or a prn medication administered 2 hours after a major surgery would not be the most effective. The medication that is administered intramuscularly is not typically recommended for moderateto-severe pain that will require more than one dose. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 11.10.3. Examine diagnosis and treatment of chronic inflammatory bowel disease. Page Number: 165 Question 19 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCMA A patient recovering from abdominal surgery is refusing hydromorphone (Dilaudid) because she has heard that it may be addictive. She is crying and rates her pain at 10 out of 10. What statements should the nurse include as part of the patient’s education? Standard Text: 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 have an increased risk of blood clots. 4. Dehydration can result from poorly managed pain. 5. Family members will not want to visit patients showing visible signs of pain. Correct Answer: 1,2,3 Rationale 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. Rationale 2: Pain causes physiological consequences, including poor wound healing. Rationale 3: Pain causes physiological consequences, including coagulation leading to DVT or PE. Rationale 4: There is no evidence that poor pain relief causes dehydration. Rationale 5: There is no evidence that poor pain relief causes family members to refuse to visit. Global Rationale: 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. Pain causes physiological consequences, including poor wound healing and coagulation leading to DVT or PE. There is no evidence that poor pain relief causes dehydration or refusal by family members to visit. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 11.10.3. Examine diagnosis and treatment of chronic inflammatory bowel disease. Page Number: 158 Question 20 Type: MCSA A patient is refusing to take pain medication for chronic back pain. The nurse asks the patient 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 Correct Answer: 1 Rationale 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. Rationale 2: The nurse is not attempting to question the patient’s admission or stay in the hospital. Rationale 3: The nurse is not attempting to decide if the patient is being argumentative. Rationale 4: The nurse is not attempting to decide whether the patient should leave the hospital against medical advice. Global Rationale: 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. The nurse is not attempting to question the patient’s admission or stay in the hospital, to decide if the patient is being argumentative, or decide whether the patient should leave the hospital against medical advice. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 8.5.4. Utilize the nursing process in care of client. Page Number: 169-170 Question 21 Type: MCSA 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 Correct Answer: 2 Rationale 1: Assessment of peripheral pulses is done to check for presence and strength; it is not routinely done to assess a pulse rate. Rationale 2: Pain is increasingly being referred to as the “fifth vital sign,” with recommendations to include pain assessment in every vital signs assessment. Rationale 3: Ambulation is not a vital sign. Rationale 4: Urine output is not a vital sign. Global Rationale: Pain is increasingly being referred to as the “fifth vital sign,” with recommendations to include assess pain assessment in every vital signs assessment. Assessment of peripheral pulses is done to check for presence and strength; it is not routinely done to assess a pulse rate. Ambulation and urine output are not vital signs. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 151 Question 22 Type: MCSA 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. Correct Answer: 1 Rationale 1: If the patient says he or she has pain, the patient is in pain. All pain is real. Rationale 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. Rationale 3: This is the nurse’s interpretation. Rationale 4: This is the nurse’s interpretation. Global Rationale: If the patient says he or she has pain, the patient is in pain. All pain is real. 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. Concluding that the patient is demanding or just wants attention reflects a biased interpretation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 152 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 23 Type: MCSA A patient with a history of chronic pain tells the nurse, “I do a variety of things to make my body produce its own 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 Correct Answer: 4 Rationale 1: The patient is not denying the pain. Rationale 2: Alternative methods have not been employed. Rationale 3: There was no discussion of pain medication amounts. Rationale 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 morphines), which are naturally occurring opioid 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. Global Rationale: 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 morphines), which are naturally occurring opioid 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. The patient is not denying the pain. Alternative methods have not been employed. There was no discussion of pain medication amounts. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 154 Question 24 Type: MCSA A 47-year-old female patient has a history of scoliosis and back pain. Which type of pain should the nurse realize this patient most likely is experiencing? 1. recurrent acute pain 2. ongoing time-limited pain 3. chronic malignant pain 4. chronic nonmalignant pain Correct Answer: 4 Rationale 1: Recurrent acute pain is characterized by relatively well-defined episodes of pain interspersed with pain-free episodes. Rationale 2: Ongoing time-limited pain is not a commonly used term for pain. Rationale 3: Malignancy is not mentioned as a cause of the pain. Rationale 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. Global Rationale: 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. Malignancy is not mentioned as a cause of the pain. Recurrent acute pain is characterized by relatively well-defined episodes of pain interspersed with pain-free episodes. Ongoing time-limited pain is not a commonly used term for pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: 7.6.2. Differentiate the manifestations of spinal cord disorders. Page Number: 156 Question 25 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Myofascial pain syndrome is a condition marked by injury to or disease of muscle and fascial tissue. Rationale 3: This pain was not described as chronic. Rationale 4: No amputation has been performed that might explain phantom limb pain. Global Rationale: 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. This pain was not described as chronic. No amputation has been performed that might explain phantom limb pain. Myofascial pain syndrome is a condition marked by injury to or disease of muscle and fascial tissue. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: 7.6.2. Differentiate the manifestations of spinal cord disorders. Page Number: 157 Question 26 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: With a low tolerance, the patient would be verbalizing pain and requesting medication. Rationale 3: If addicted, the patient would eventually need more medication, not less, to manage the pain. Rationale 4: There is no evidence that the patient is not in pain. Global Rationale: 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. With a low tolerance, the patient would be verbalizing pain and requesting medication. If addicted, the patient would eventually need more medication, not less, to manage the pain. There no evidence that the patient is not in pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Discuss factors affecting individualized responses to pain. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: Page Number: 158 Question 27 Type: MCSA A patient with chronic pain tells the nurse that she “rarely sleeps more than 3 hours a night.” The nurse recognizes that this patient is at risk for developing which health problem? 1. chronic insomnia 2. depression 3. high pain tolerance 4. adult attention deficit disorder Correct Answer: 2 Rationale 1: There is no evidence to support the risk of chronic insomnia, although insomnia is associated with chronic pain. Rationale 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. Rationale 3: There is no evidence to support inferences concerning pain tolerance. Rationale 4: There is no evidence to support the risk of adult attention deficit disorder. Global Rationale: 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. There is no evidence to support the risk of chronic insomnia or adult attention deficit disorder, or inferences concerning pain tolerance. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 157 -158 Question 28 Type: MCSA 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 Correct Answer: 4 Rationale 1: The pain has already been identified as being real and chronic in nature. Rationale 2: Avoidance of narcotics may not meet the patient’s immediate needs. Rationale 3: There is no mention of a depressed state, only the patient’s need to address the pain. Rationale 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. Global Rationale: 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. The pain has already been identified as being real and chronic in nature. There is no mention of a depressed state, only the patient’s need to address the pain. Avoidance of narcotics may not meet the patient’s immediate needs. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 163 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 29 Type: MCSA A patient has periodic severe nerve pain that is not well controlled with pain medication. The nurse thinks that this patient might benefit from which pain management approach? 1. a nonsteroidal anti-inflammatory drug (NSAID) 2. a narcotic 3. an antidepressant 4. a local anesthetic Correct Answer: 3 Rationale 1: The NSAID group can have serious side effects, including bleeding tendencies, and would not be appropriate in a long-term situation. Rationale 2: Other medications are prescribed before introducing narcotics. Rationale 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. Rationale 4: A local anesthetic would not be appropriate for long-term pain management. Global Rationale: 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. Other medications are prescribed before introducing narcotics. The NSAID group can have serious side effects, including bleeding tendencies, and would not be appropriate in a long-term situation. A local anesthetic would not be appropriate for long-term pain management. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 7.6.3. Examine the diagnosis and treatment of spinal cord disorders. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 162 Question 30 Type: MCSA 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 ordered for breakthrough pain. 2. Talk the patient through the pain. 3. Encourage the patient to ignore the pain. 4. Give the patient a nonsteroidal anti-inflammatory drug (NSAID). Correct Answer: 1 Rationale 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. Rationale 2: The pain must be addressed; it is not appropriate to talk the patient through the pain. Rationale 3: The pain must be addressed; it is not appropriate to encourage the patient to ignore the pain. Rationale 4: NSAIDs can only be given with the physician’s order. Global Rationale: 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. The pain must be addressed; it is not appropriate to talk the patient through the pain or encourage the patient to ignore the pain. NSAIDs can only be given with the physician’s order. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 157 Question 31 Type: MCSA 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. Correct Answer: 2 Rationale 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. Rationale 2: Dosages for the “patch” start low and are increased as deemed necessary by the physician. Rationale 3: Additional short-acting medication is often needed for breakthrough pain. Rationale 4: Overdosage can occur with this route. Global Rationale: Dosages for the “patch” start low and are increased as deemed necessary by the physician. 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. Additional shortacting medication is often needed for breakthrough pain. Overdosage can occur with this route. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 165 Question 32 Type: MCSA The nurse is helping a patient in pain by gently massaging the painful area. The nurse is utilizing which form of pain control with the patient? 1. acupuncture 2. biofeedback 3. guided imagery 4. cutaneous stimulation Correct Answer: 4 Rationale 1: There is no mention of the use of acupuncture needles. Rationale 2: Biofeedback does not involve massage. Rationale 3: Guided imagery does not involve massage. Rationale 4: It is believed that stimulation of the skin is effective in relieving pain because it prompts closure of the gate in the substantia gelatinosa. Cutaneous stimulation may be accomplished by massage, vibration, applying heat and cold, and therapeutic touch. Global Rationale: It is believed that stimulation of the skin is effective in relieving pain because it prompts closure of the gate in the substantia gelatinosa. Cutaneous stimulation may be accomplished by massage, vibration, applying of heat and cold, and therapeutic touch. Touch was used, so biofeedback and guided imagery are not correct. There is no mention of the use of acupuncture needles. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 173 Question 33 Type: MCSA The nurse is assessing a patient’s pain perception. What should the nurse use to make this assessment? 1. FACES scale 2. psychological evaluation tool 3. PQRST guide 4. biofeedback rating Correct Answer: 3 Rationale 1: The FACES scale is a pain rating tool. Rationale 2: Use of a psychological evaluation tool is not indicated. Rationale 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? Rationale 4: A biofeedback rating would not address all areas of a pain assessment. Global Rationale: 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? The FACES scale is a pain rating tool. Use of a psychological evaluation tool is not indicated. A biofeedback rating would not address all areas of a pain assessment. Cognitive Level: Applying Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Basic Care and Comfort 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 170 Question 34 Type: MCSA 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 Correct Answer: 4 Rationale 1: No mention is made of the patient requesting narcotics. Rationale 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. Rationale 3: The nurse cannot decide if the patient’s pain is real. Rationale 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. Global Rationale: 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. The nurse cannot decide if the patient’s pain is real. No mention is made of the patient requesting narcotics. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: Page Number: 171 Question 35 Type: MCHS A patient is hospitalized with suspected gallstones and inflammatory gallbladder disease. Place an “X” over the area of the body where the nurse would expect the patient to locate the pain.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Referred pain is pain that is perceived in an area distant from the site of the stimuli. It commonly occurs with pain that originates in thoracic or abdominal viscera. Visceral sensory fibers synapse at the level of the spinal cord, close to fibers innervating other subcutaneous tissue areas of the body. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: 11.4.2. Differentiate the manifestations of gallbladder disorders. Page Number: 155 Question 36 Type: MCHS A patient with a history of high blood pressure and cardiac arrhythmias is admitted after having EKG changes consistent with a myocardial infarction. Place an “X” over the area of the body where the nurse would expect the patient to locate the pain.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Referred pain is pain that is perceived in an area distant from the site of the stimuli. It commonly occurs with pain that originates in thoracic or abdominal viscera. Visceral sensory fibers synapse at the level of the spinal cord, close to fibers innervating other subcutaneous tissue areas of the body. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: 6.4.1. Explain the incidence and pathophysiology for cardiac perfusion disorders. Page Number: 155 Question 37 Type: MCSA The nurse is reviewing data for several patients. Which physiologic assessment findings should the nurse recognize are consistent with those of an adult experiencing acute pain?
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1. Patients A and C 2. Patient A only 3. Patients B and D 4. Patient C only Correct Answer: 3 Rationale 1: Equal pupillary response, respiratory changes, and normal skin assessment are not predictable physiological changes with acute pain.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Equal pupillary response and respiratory changes are not predictable physiological changes with acute pain. Rationale 3: Predictable physiologic changes occur in the presence of acute pain. These may include muscle tension; tachycardia; rapid, shallow respirations; increased blood pressure; dilated pupils; sweating; and pallor. Rationale 4: Normal skin assessment is not a predictable physiological change with acute pain. Global Rationale: Predictable physiologic changes occur in the presence of acute pain. These may include muscle tension; tachycardia; rapid, shallow respirations; increased blood pressure; dilated pupils; sweating; and pallor. Equal pupillary response, respiratory changes, and normal skin assessment are not predictable physiological changes with acute pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: Page Number: 156 Question 38 Type: MCSA The nurse is reviewing the care provided to a group of patients. Which patient’s/patients’ symptoms are most likely side effects of an opioid pain medication treatment regimen?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Patients A and C 2. Patient C only 3. Patients B and D 4. Patient D only Correct Answer: 1 Rationale 1: Nausea and vomiting are common adverse effects of opioid analgesics, as is constipation. Rationale 2: Another patient is also experiencing the effects of opioid analgesics. Rationale 3: Opioids are not typically given for stomach pain prior to a meal. Bruising is not a common side effect of opioid administration. Rationale 4: Bruising is not a common side effect of opioid administration. Global Rationale: Opioid analgesics are CNS and respiratory depressants and tend to have similar unintended effects. They commonly produce sedation, drowsiness, and dizziness. Nausea and vomiting are common adverse effects, as is constipation. Opioids are not typically given for stomach pain prior to a meal. Bruising is not a common side effect of opioid administration. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 162 Question 39 Type: MCSA The nurse is evaluating the pain descriptions of a group of patients. Which patient’s/patients’ description is consistent with that of phantom pain?
1. Patients A and D 2. Patient A only 3. Patients B and D 4. Patient C only Correct Answer: 4 Rationale 1: Patients A and D have a low risk of experiencing phantom pain. Rationale 2: Patient A has a low risk of experiencing phantom pain. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Patients B and D have a low risk of experiencing phantom pain. Rationale 4: Patient C has an increased risk of experiencing phantom pain. Phantom pain is a type of neuropathic pain that occurs after amputations. Global Rationale: Patient C has an increased risk of experiencing phantom pain. Phantom pain is a type of neuropathic pain that occurs after amputations. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: Page Number: 157 Question 40 Type: FIB A patient has been receiving morphine sulfate 10 mg intramuscularly every 4 hours for the past few days. The nurse is anticipating discharge and wants to calculate the oral dose necessary for this patient. Calculate the oral dosage range using the equianalgesic dosing formula: ___ mg. Standard Text: Record your answer rounding to the nearest whole number, using a dash (“-“) to indicate the range. Correct Answer: 30-60 Rationale: The PO dose is 3 to 6 times the IM dose. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 161 Question 41 Type: FIB A patient is prescribed a fentanyl patch to administer 100 mcg/hour. The patient uses one patch for 72 hours and then is changed to an intravenous infusion of morphine 8 hours into the second patch. If the patient had been receiving the morphine intravenously, how many mg of the medication would the patient have received from wearing the patch? Standard Text: Record your answer rounding to the nearest whole number. Correct Answer: 320 mg Rationale: 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. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 161 Question 42 Type: SEQ 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: Click and drag the options below to move them up or down. 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 Correct Answer: 4, 2, 3, 1 Rationale 1: Morphine is the strongest of these pain medications. It is an opioid. Rationale 2: Ibuprofen is a nonopioid and is the second weakest of these medications. Rationale 3: Propoxyphene is the second strongest of these medications. Rationale 4: Tylenol is the weakest of these medications. Global Rationale: The nonopioid analgesics acetaminophen and ibuprofen are the least invasive, followed by the mild opioid analgesics with adjuvant therapy, and finally the opioids. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 160 Question 43 Type: SEQ 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? Standard Text: Click and drag the options below to move them up or down.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 4,2,3,1 Rationale 1: This is the final step in the neural pain pathway. Rationale 2: This is the second step in the neural pain pathway. Rationale 3: This is the third step in the neural pain pathway. Rationale 4: This is the first step in the neural pain pathway. Global Rationale: The neural pain pathway physiology follows this order: 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. Dorsal horn synapses relay impulses up the spinal cord. Spinal neurons transmit the impulses via axons that cross over to the spinothalamic tract. The impulses ascend the spinothalamic tracts and pass through the medulla and midbrain to the thalamus. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the neurophysiology of pain. MNL Learning Outcome: Page Number: 154 Question 44 Type: SEQ LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is preparing to apply a transdermal analgesic patch to a patient. In what order should the nurse administer this medication? Standard Text: Click and drag the options below to move them up or down. 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. Correct Answer: 1, 2, 4, 3 Rationale 1: A transdermal patch is applied to a clean, dry area on the upper torso. Rationale 2: If hair is present, it should be clipped before applying the patch. Rationale 3: The patch is effective for about 72 hours. Rationale 4: Apply the patch immediately after opening the package, ensuring complete contact with the skin, especially around the edges. Global Rationale: A transdermal patch is applied to a clean, dry area on the upper torso. If hair is present, it should be clipped before applying the patch. Apply the patch immediately after opening the package, ensuring complete contact with the skin, especially around the edges. The patch is effective for about 72 hours. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 165 Question 45 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A nurse is teaching pain management to a homebound hospice patient, already being treated with opioids. This patient has been diagnosed with metastatic breast cancer and expresses anxiety about keeping her pain under control. In which nonpharmacologic complementary methods might the nurse instruct the patient? Standard Text: Select all that apply. 1. guided imagery 2. progressive muscle relaxation 3. distraction 4. acupuncture 5. regional pain management Correct Answer: 1, 2, 3 Rationale 1: Guided imagery can be taught to the patient by the nurse. Rationale 2: Progressive muscle relaxation can be taught to the patient by the nurse. Rationale 3: Distraction can be taught to the patient by the nurse. Rationale 4: Acupuncture cannot be taught to the patient by the nurse. Acupuncture can only be provided by persons with special training. Rationale 5: Regional pain management is not an alternative complementary therapy. Global Rationale: Guided imagery, progressive muscle relaxation, and distraction can be taught by the nurse. Acupuncture can only be provided by persons with special training. Regional pain management is not an alternative complementary therapy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: 13.1.4. Utilize the nursing process in care of client. Page Number: 168 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 46 Type: MCMA The nurse is caring for older patients in a long-term-care facility. The nurse understands that which factors influence pain management in these patients? Standard Text: 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. Correct Answer: 2, 3, 5 Rationale 1: There is actually decreased fiber transmission and no greater risk of dependence with older adults. Rationale 2: There is an increased risk of depression in the older patient experiencing chronic pain. Rationale 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. Rationale 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. Rationale 5: The older adult may present with manifestations such as delirium rather than subjective reports of pain. Global Rationale: In older adults there are decreased fiber transmission, no greater risk for addiction, and an increased risk of depression related to chronic pain. There is also a lower level of reported referred pain, so that the patient may not exhibit classic symptoms of myocardial infarction. 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. The older adult may present with manifestations such as delirium rather than subjective reports of pain. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.3. Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Discuss factors affecting individualized responses to pain. MNL Learning Outcome: Page Number: 158 Question 47 Type: MCMA A patient recovering from a broken leg asks why the pain is so sharp. What should the nurse explain about acute pain? Standard Text: 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. Correct Answer: 3, 4, 5 Rationale 1: The release of catecholamines explains the cardiovascular response to pain. Rationale 2: The reduction of blood flow to the gut explains why nausea and vomiting occur with pain. Rationale 3: With sharp local pain, nociceptors transmit pain stimuli along myelinated fibers to the spinal cord. Rationale 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. Rationale 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). Global Rationale: 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. From the thalamus, the stimulus is distributed to the somatosensory cortex (perception and interpretation), the limbic system (emotional responses to pain), and brainstem centers (autonomic nervous system responses). The release of catecholamines explains the cardiovascular response to pain. The reduction of blood flow to the gut explains why nausea and vomiting occur with pain. Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the neurophysiology of pain. MNL Learning Outcome: 8.1.2. Compare the manifestations of traumatic musculoskeletal injuries. Page Number: 156 Question 48 Type: MCSA A patient with bone pain complains that the pain is more intense when the patient is being repositioned in bed. For which type of pain should the nurse plan care? 1. Central 2. Incident 3. Nociceptive 4. Neuropathic Correct Answer: 2 Rationale 1: Central pain is caused by a lesion or damage in the brain or spinal cord. Rationale 2: Incident or episodic pain is predictable, precipitated by an event or activity such as coughing, changing position, or being touched. Rationale 3: Nociceptive pain is caused by stimulation of peripheral or visceral pain receptors. Rationale 4: Neuropathic pain arises as a consequence of a lesion or disease affecting the somatosensory system. Global Rationale: Incident or episodic pain is predictable, precipitated by an event or activity such as coughing, changing position, or being touched. Central pain is caused by a lesion or damage in the brain or spinal cord. Nociceptive pain is caused by stimulation of peripheral or visceral pain receptors. Neuropathic pain arises as a consequence of a lesion or disease affecting the somatosensory system. Cognitive Level: Application Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Compare and contrast definitions and characteristics of acute, chronic, central, and phantom pain. MNL Learning Outcome: 8.1.2. Compare the manifestations of traumatic musculoskeletal injuries. Page Number: 157 Question 49 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 4, 5 Rationale 1: NSAIDs are not recommended for use in people with peptic ulcer disease. Rationale 2: A pacemaker would not be a contraindication for using NSAIDs. Rationale 3: Total joint replacements are not a reason to contraindicate NSAIDs. Rationale 4: NSAIDs are not recommended for use in people with bleeding disorders. Rationale 5: NSAIDs are not recommended for use in people with kidney or liver disease. Global Rationale: NSAIDs are not recommended for use in people with kidney or liver disease, bleeding disorders, or peptic ulcer disease. A pacemaker would not be a contraindication for using NSAIDs. Total joint replacements are not a reason to contraindicate NSAIDs. Cognitive Level: Analysis Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 160 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 50 Type: MCMA A patient with chronic pain is prescribed an anticonvulsant medication. What should the nurse instruct the patient to expect when taking this medication? Standard Text: Select all that apply. 1. Less nausea 2. Reduced pain 3. Improved sleep 4. Improved mobility 5. Reduced urine output Correct Answer: 2, 3 Rationale 1: Anticonvulsants are not prescribed to reduce nausea. Rationale 2: Anticonvulsants are frequently used with opioids in pain control because these drugs reduce pain. Rationale 3: Anticonvulsants are frequently used with opioids in pain control because these drugs reduce sleep disruption. Rationale 4: Anticonvulsants are not prescribed to improve mobility. Rationale 5: Anticonvulsants should not adversely affect renal functioning. Global Rationale: Anticonvulsants are frequently used with opioids in pain control because these drugs reduce pain and sleep disruption. Anticonvulsants are not prescribed to reduce nausea or improve mobility. They should not adversely affect renal functioning. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 162 Question 51 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCMA A patient is prescribed hydrocodone (Vicodin) for severe tooth pain. What should the nurse instruct the patient about taking this mediation? Standard Text: 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. Correct Answer: 1, 2, 4, 5 Rationale 1: The nurse should instruct the patient to avoid drinking alcohol while taking this medication. Rationale 2: The nurse should instruct the patient to use caution or avoid driving when taking this medication. Rationale 3: Respiratory depression can occur when taking this medication; however, it is not an expected effect and should be reported to the healthcare provider. Rationale 4: The nurse should instruct the patient to increase the intake of fluids and fiber to prevent constipation. Rationale 5: The nurse should instruct the patient not to take over-the-counter medications unless approved by the healthcare provider. Global Rationale: The nurse should instruct the patient to avoid drinking alcohol while taking this medication, to use caution or avoid driving, to increase the intake of fluids and fiber to prevent constipation, and not to take overthe-counter medications unless approved by the healthcare provider. Respiratory depression can occur when taking this medication; however, it is not an expected effect and should be reported to the healthcare provider. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Describe interprofessional care for the patient in pain, including medications, surgery, transcutaneous electrical nerve stimulation, and complementary therapies. MNL Learning Outcome: Page Number: 164
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 10 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The risks for kidney damage are not specifically related to aging or fluid and electrolyte issues. Rationale 3: The risk of stroke is not specifically related to aging or fluid and electrolyte issues. Rationale 4: The risk of bleeding is not specifically related to aging or fluid and electrolyte issues. Global Rationale: 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. The risks for kidney damage, stroke, and bleeding are not specifically related to aging or fluid and electrolyte issues. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.1.1. Examine the pathophysiology of fluid imbalances. Page Number: 183
Question 2 Type: MCSA The nurse is planning care for a patient with severe burns. What condition 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 Correct Answer: 1 Rationale 1: Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. Rationale 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. Rationale 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. Rationale 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. Global Rationale: Because this patient was severely burned, the fluid within the cells is diminished, leading to an intracellular fluid deficit. The intracellular fluid is composed of all fluids that exist within the cell cytoplasm and nucleus. The extracellular fluid is composed of all fluids that exist outside the cell, including the interstitial fluid between the cells. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.1.1. Examine the pathophysiology of fluid imbalances. Page Number: 184
Question 3 Type: MCSA A patient experiencing multisystem fluid volume deficit has tachycardia; pale, cool skin; and decreased urine output. The nurse realizes these findings are most likely a direct result of which process? 1. the body’s natural compensatory mechanisms 2. pharmacological effects of a diuretic 3. effects of rapidly infused intravenous fluids 4. cardiac failure Correct Answer: 1 Rationale 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. Rationale 2: No evidence is provided that the patient received a diuretic. Rationale 3: Rapidly infused intravenous fluids would not cause a decrease in urine output. Rationale 4: The manifestations reported are not indicative of cardiac failure in this patient. Global Rationale: 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. No evidence is provided that the patient received a diuretic. Rapidly infused intravenous fluids would not cause a decrease in urine output. The manifestations reported are not indicative of cardiac failure in this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 185
Question 4 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: There is no evidence that the patient has an overabundance of fluid. Rationale 3: There is no evidence that the patient has a nutritional deficiency. Rationale 4: There is no evidence that this patient has insufficient blood flow. Global Rationale: The patient with excessive thirst and increased urination is losing fluid. This is the problem that the nurse should focus with this patient. There is no evidence that the patient has an overabundance of fluid. There is no evidence that the patient has a nutritional deficiency. There is no evidence that this patient has insufficient blood flow. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 188
Question 5 Type: MCSA A patient recovering from surgery has an indwelling urinary catheter. For which 24-hour urine output volumes should the nurse notify the patient’s healthcare provider? 1. 600 milliliters 2. 750 milliliters 3. 1000 milliliters 4. 1200 milliliters Correct Answer: 1 Rationale 1: A urine output of less than 30 milliliters 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 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Rationale 2: There is no reason to report this volume to the healthcare provider. A minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Rationale 3: There is no reason to report this volume to the healthcare provider. A minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Rationale 4: There is no reason to report this volume to the healthcare provider. A minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours).
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: A urine output of less than 30 milliliters 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. There is no reason to report the volumes of 750 mL, 1000 mL, or 1200 mL to the healthcare provider because a minimum of 720 milliliters over a 24-hour period is desired (30 milliliters multiplied by 24 hours equals 720 milliliters per 24 hours). Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 188
Question 6 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Adding more fluids intravenously can cause a fluid volume excess, not fluid volume deficit, and stress upon the heart and circulatory system. Rationale 3: Seizure activity would more commonly be associated with electrolyte imbalances. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Liver failure is not anticipated related to postoperative intravenous fluid administration. Global Rationale: 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. Liver failure is not anticipated related to postoperative intravenous fluid administration. Seizure activity would more commonly be associated with electrolyte imbalances. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 183
Question 7 Type: MCSA A patient is diagnosed with severe hyponatremia. The nurse realizes this patient will mostly likely need precautions implemented for what event? 1. seizure 2. infection 3. neutropenia 4. high-risk fall Correct Answer: 1 Rationale 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. Rationale 2: Infection precautions are not specifically indicated for a patient with hyponatremia. Rationale 3: Neutropenic precautions are not specifically indicated for a patient with hyponatremia. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: High-risk fall precautions are not specifically indicated for a patient with hyponatremia. Global Rationale: 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. Infection or neutropenia precautions and high-risk fall precautions are not specifically indicated for a patient with hyponatremia. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.2.2. Differentiate the manifestations of a sodium imbalance. Page Number: 195
Question 8 Type: MCSA A patient is diagnosed with hypokalemia. After reviewing the patient’s current medications, which drug should the nurse consider that might have contributed to the patient’s health problem? 1. corticosteroid 2. thiazide diuretic 3. narcotic 4. muscle relaxer Correct Answer: 1 Rationale 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. Rationale 2: Excessive sodium is lost with the use of thiazide diuretics. Rationale 3: Narcotics do not typically affect electrolyte balance. Rationale 4: Muscle relaxants do not typically affect electrolyte balance. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Excessive sodium is lost with the use of thiazide diuretics. Narcotics and muscle relaxers do not typically affect electrolyte balance. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.1. Examine the causes and pathophysiology of a potassium imbalance. Page Number: 196
Question 9 Type: MCSA A patient prescribed spironolactone is demonstrating ECG changes and complaining of muscle weakness. The nurse realizes this patient is exhibiting signs of which electrolyte imbalance? 1. hyperkalemia 2. hypokalemia 3. hypercalcemia 4. hypocalcemia Correct Answer: 1 Rationale 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. Rationale 2: Hypokalemia is seen in nonpotassium diuretics such as furosemide. Rationale 3: Hypercalcemia has been associated with thiazide diuretics.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use. Global Rationale: 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. Hypokalemia is seen in non-potassium diuretics such as furosemide. Hypercalcemia has been associated with thiazide diuretics. Hypocalcemia is seen in patients who have received many units of citrated blood and is not associated with diuretic use. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.1. Examine the causes and pathophysiology of a potassium imbalance. Page Number: 200
Question 10 Type: MCSA 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. Correct Answer: 1 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia. Rationale 3: Kayexalate is used in patients with hyperkalemia. Rationale 4: The administration of normal saline with furosemide is used to increase calcium secretion. Global Rationale: 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. The administration of intravenous fluids would be indicated in fluid volume deficit and hypernatremia. Kayexalate is used in patients with hyperkalemia. The administration of normal saline with furosemide is used to increase calcium secretion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.2.3. Examine the diagnosis and treatment of a sodium imbalance. Page Number: 194
Question 11 Type: MCSA The nurse is caring for a patient diagnosed with hypocalcemia. What additional assessments should the nurse include when caring for this patient? 1. other electrolyte disturbances 2. hypertension 3. visual disturbances 4. drug toxicity Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. Rationale 2: The patient with hypocalcemia may exhibit hypotension, and not hypertension. Rationale 3: Visual disturbances do not occur with hypocalcemia. Rationale 4: Hypercalcemia is more commonly caused by drug toxicities. Global Rationale: The patient diagnosed with hypocalcemia may also have high phosphorus or decreased magnesium levels. The patient with hypocalcemia may exhibit hypotension, and not hypertension. Visual disturbances do not occur with hypocalcemia. Hypercalcemia is more commonly caused by drug toxicities. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.4.2. Explain the manifestations and complications of a calcium imbalance. Page Number: 205
Question 12 Type: MCSA 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 to avoid the intake of sodium phosphate. Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet. Rationale 2: Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Rationale 3: Poultry, peanuts, and seeds are part of a high phosphate diet. Rationale 4: Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate. Global Rationale: Treatment of hypophosphatemia includes treating the underlying cause and promoting a high phosphate diet. Phosphate-binding antacids, such as aluminum hydroxide, should be avoided. Mild hypophosphatemia may be corrected by oral supplements, such as sodium phosphate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.6.3. Examine the diagnosis and treatment of a phosphorus imbalance. Page Number: 212
Question 13 Type: MCSA 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. Correct Answer: 1 Rationale 1: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Excreting bicarbonate causes acidosis to develop. Rationale 3: Retaining carbon dioxide causes respiratory acidosis. Rationale 4: Excreting carbon dioxide causes respiratory alkalosis. Global Rationale: The kidneys will compensate for a respiratory disorder by retaining bicarbonate. Excreting bicarbonate causes acidosis to develop. Retaining carbon dioxide causes respiratory acidosis. Excreting carbon dioxide causes respiratory alkalosis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.1. Apply nursing process as framework to provide nursing care to the client with respiratory acidosis. Page Number: 223
Question 14 Type: MCSA 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. Correct Answer: 1 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 3: Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. Rationale 4: Oxygenation disturbance is not part of the acid–base status of the patient with renal failure. Global Rationale: 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. 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. Metabolic acidosis of renal failure causes a low pH; this is the manifestation of the disease process, not the compensation. Oxygenation disturbance is not part of the acid–base status of the patient with renal failure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.3. Apply nursing process as framework to provide nursing care to the client with metabolic acidosis. Page Number: 217
Question 15 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: A patient receiving dialysis has kidney failure, which causes metabolic acidosis. Rationale 3: A venous stasis ulcer does not result in an acid‒base disorder. Rationale 4: The patient diagnosed with COPD typically has hypercapnea and respiratory acidosis. Global Rationale: 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. A patient receiving dialysis has kidney failure, which causes metabolic acidosis. A venous stasis ulcer does not result in an acid‒base disorder. The patient diagnosed with COPD typically has hypercapnea and respiratory acidosis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.4. Apply nursing process as framework to provide nursing care to the client with metabolic alkalosis. Page Number: 221
Question 16 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: Not enough information is given to determine the need for intravenous fluids. Rationale 4: Bicarbonate would be contraindicated as the pH is already high. Global Rationale: 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. 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. Not enough information is given to determine the need for intravenous fluids. Bicarbonate would be contraindicated as the pH is already high. Cognitive Level: Evaluating Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.2. Apply nursing process as framework to provide nursing care to the client with respiratory alkalosis. Page Number: 226
Question 17 Type: MCSA A patient is prescribed 20 mEq of potassium chloride. The nurse realizes that the reason the patient is receiving this replacement is 1. to sustain respiratory function. 2. to help regulate acid‒base balance. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. to keep a vein open. 4. to encourage urine output. Correct Answer: 2 Rationale 1: Potassium does not sustain respiratory function. Rationale 2: Potassium, the primary intracellular cation, plays a vital role in cell metabolism and cardiac and neuromuscular function. Rationale 3: Intravenous fluids are used to keep venous access, not potassium. Rationale 4: Urinary output is impacted by fluid intake not potassium. Global Rationale: Potassium, the primary intracellular cation, plays a vital role in cell metabolism and cardiac and neuromuscular function. Potassium does not sustain respiratory function. Intravenous fluids are used to keep venous access not potassium. Urinary output is impacted by fluid intake not potassium. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.3.1. Examine the causes and pathophysiology of a potassium imbalance. Page Number: 196
Question 18 Type: MCSA An elderly patient does not complain of thirst. What should the nurse do to assess that this patient is not dehydrated? 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Ask the physician for an order for a brain scan. Correct Answer: 3 Rationale 1: It is inappropriate to seek an IV at this stage. Rationale 2: There is no indication the patient is experiencing pulmonary complications, thus a chest x-ray is not indicated. Rationale 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. Rationale 4: There is no data to support the need for a brain scan. Global Rationale: 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. It is inappropriate to seek an IV at this stage. There is no indication the patient is experiencing pulmonary complications, thus a chest x-ray is not indicated. There is no data to support the need for a brain scan. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.2.3. Examine the diagnosis and treatment of a sodium imbalance. Page Number: 195
Question 19 Type: MCSA An elderly patient who is being medicated for pain had an episode of incontinence. The nurse realizes that this patient is at risk for developing 1. dehydration. 2. over-hydration. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. fecal incontinence. 4. a stroke. Correct Answer: 1 Rationale 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. Rationale 2: There is inadequate evidence to support the risk of over-hydration. Rationale 3: There is inadequate evidence to support the risk of fecal incontinence. Rationale 4: There is inadequate evidence to support the risk of a stroke. Global Rationale: Functional changes of aging also affect fluid balance. Fear of incontinence can lead to selflimiting of fluid intake. 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. There is inadequate information to support the risk of over-hydration, fecal incontinence, or a stroke. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 184
Question 20 Type: FIB The nurse assesses a patient’s weight loss as being 22 lbs. How many liters of fluid did this patient lose? Standard Text: Correct Answer: 10 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale: Each liter of body fluid weighs 1 kg or 2.2 lbs. This patient has lost 10 liters of fluid. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 185
Question 21 Type: MCSA 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. Correct Answer: 3 Rationale 1: The patient should avoid prolonged standing. Rationale 2: Bed rest can promote skin breakdown. Rationale 3: The patient needs to be taught how to avoid orthostatic hypotension, which involves assisting and teaching the patient how to move from one position to another in stages. Rationale 4: A physician referral is needed for physical therapy intervention and is not indicated in this situation.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The patient needs to be taught how to avoid orthostatic hypotension, which involves assisting and teaching the patient how to move from one position to another in stages. The patient should avoid prolonged standing. Bed rest can promote skin breakdown. A physician referral is needed for physical therapy intervention and is not indicated in this situation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 188
Question 22 Type: MCSA 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 Correct Answer: 3 Rationale 1: Poor skin turgor is associated with fluid volume deficit. Rationale 2: Decreased urine output is associated with fluid volume deficit. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Increased hemoglobin and hematocrit values are associated with fluid volume deficit. Global Rationale: 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. The other answers indicate a fluid volume deficit. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 190
Question 23 Type: MCSA An older patient is at home after being diagnosed with fluid volume overload. What should the home care 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. Correct Answer: 1 Rationale 1: The home care nurse should instruct this patient about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, and resting in a recliner or bed with extra pillows. Rationale 2: The patient should elevate the legs. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: As long as the shoes are well fitting, there is no reason to avoid wearing them. Rationale 4: It is appropriate for the patient to use extra pillows to keep the head up while sleeping. Global Rationale: The home care nurse should instruct this patient about ways to decrease dependent edema, which include wearing support hose, elevating feet when in a sitting position, and resting in a recliner or bed with extra pillows. As long as the shoes are well fitting, there is no reason to avoid wearing them. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 193
Question 24 Type: MCSA A patient with fluid retention related to renal problems is admitted to the hospital. The nurse realizes that this patient could possibly have which electrolyte imbalance? 1. hypokalemia 2. hypernatremia 3. carbon dioxide 4. magnesium Correct Answer: 2 Rationale 1: The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations potassium levels. Rationale 2: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Carbon dioxide abnormalities are not normally seen in this type of patient. Rationale 4: Magnesium abnormalities are not normally seen in this type of patient. Global Rationale: The kidney is the primary regulator of sodium in the body. Fluid retention is associated with hypernatremia. The kidneys are the principal organs involved in the elimination of potassium. Renal failure is often associated with elevations in potassium levels. Carbon dioxide and magnesium abnormalities are not anticipated for this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.2.1. Explain the causes and pathophysiology of a sodium imbalance. Page Number: 195
Question 25 Type: MCSA An older patient comes into the clinic complaining of watery diarrhea for several days with abdominal and muscle cramping. The nurse realizes that this patient is demonstrating which imbalance? 1. hypernatremia 2. hyponatremia 3. fluid volume excess 4. hyperkalemia Correct Answer: 2 Rationale 1: Hypernatremia is associated with fluid retention and overload. Fluid volume excess is associated with hypernatremia. Rationale 2: This elderly patient has watery diarrhea, which contributes to the loss of sodium. The abdominal and muscle cramps are manifestations of a low serum sodium level. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: This patient is more likely to develop clinical manifestations associated with fluid volume deficit. Rationale 4: Hyperkalemia is associated with cardiac dysrhythmias. Global Rationale: This elderly patient has watery diarrhea, which contributes to the loss of sodium. The abdominal and muscle cramps are manifestations of a low serum sodium level. Hypernatremia is associated with fluid retention and overload. Fluid volume excess is associated with hypernatremia. Hyperkalemia is associated with cardiac dysrhythmias. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.2.1. Explain the causes and pathophysiology of a sodium imbalance. Page Number: 194
Question 26 Type: MCSA 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 Correct Answer: 3 Rationale 1: Pulmonary edema is not associated with dehydration. Rationale 2: Atrial dysrhythmias are not a factor for this patient.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 4: There have been no activities to support the development or occurrence of stress fractures. Global Rationale: 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. The patient in question would face dehydration. Pulmonary edema is not associated with dehydration. Atrial dysrhythmias are not a factor for this patient. There have been no activities to support the development or occurrence of stress fractures. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.2.1. Explain the causes and pathophysiology of a sodium imbalance. Page Number: 195
Question 27 Type: MCSA The nurse is admitting a patient who was 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 Correct Answer: 4 Rationale 1: This patient will not be likely to develop a calcium imbalance. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: This patient will not be likely to develop a magnesium imbalance. Rationale 3: This patient will not be likely to develop a phosphorous imbalance. Rationale 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. Global Rationale: 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. Imbalances in calcium, magnesium, and phosphorus are not likely. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.1. Examine the causes and pathophysiology of a potassium imbalance. Page Number: 200
Question 28 Type: MCSA 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. Correct Answer: 1 Rationale 1: Hypokalemia increases the risk of digitalis toxicity in patients who receive this drug for heart failure. Rationale 2: More digoxin is not needed. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: A diuretic may cause further fluid loss. Rationale 4: There is inadequate information to assess for concerns related to fluid volume deficits. Global Rationale: Hypokalemia increases the risk of digitalis toxicity in patients who receive this drug for heart failure. More digoxin is not needed. A diuretic may cause further fluid loss. There is inadequate information to assess for concerns related to fluid volume deficits. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.1. Examine the causes and pathophysiology of a potassium imbalance. Page Number: 200
Question 29 Type: MCSA 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 Correct Answer: 2 Rationale 1: Never administer undiluted potassium directly into a vein. Rationale 2: The intravenous route is the recommended route for diluted potassium. Rationale 3: The nurse should administer diluted potassium into the patient’s intravenous line. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The nurse should administer diluted potassium into the patient’s intravenous line. Global Rationale: The intravenous route is the recommended route for diluted potassium. Never administer undiluted potassium directly into a vein. It is not administered rectally. It is not given via IM injection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.1. Examine the causes and pathophysiology of a potassium imbalance. Page Number: 198
Question 30 Type: MCSA An older patient with a history of sodium retention arrives to at the clinic with the complaints of “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?” Correct Answer: 4 Rationale 1: Although this patient may be prescribed digoxin, this is not the primary focus of this question. Rationale 2: The patient’s bowel habits are not of concern at this time. Rationale 3: The cardiac and musculoskeletal discomforts being reported are not consistent with physical exertion.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Global Rationale: 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. Although this patient may be prescribed digoxin this is not the primary focus of this question. The patient’s bowel habits are not of concern at this time. The cardiac and musculoskeletal discomforts being reported are not consistent with physical exertion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.2.1. Explain the causes and pathophysiology of a sodium imbalance. Page Number: 190
Question 31 Type: MCSA A 35-year-old female 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. Correct Answer: 3 Rationale 1: This patient should avoid alcohol. Rationale 2: This patient can benefit from sun exposure. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: This patient is at risk for developing hypocalcemia. This risk can be avoided if instructed to ingest milk and milk-based products. Rationale 4: Protein monitoring is not indicated. Global Rationale: This patient is at risk for developing hypocalcemia. This risk can be avoided if the patient is instructed to ingest milk and milk-based products, has adequate exposure to the sun, and avoids alcoholic beverages. The greatest dietary concern for this patient is the adequacy of calcium intake. Protein monitoring is not indicated. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.4.3. Examine the diagnosis and treatment of a calcium imbalance. Page Number: 205
Question 32 Type: MCSA 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 Correct Answer: 4 Rationale 1: If isotonic saline is not used, the patient is at risk for hyponatremia in addition to the hypercalcemia. Rationale 2: This solution is hypertonic. Rationale 3: This solution is hypertonic. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys. Global Rationale: Isotonic saline is used because sodium excretion is accompanied by calcium excretion through the kidneys. If isotonic saline is not used, the patient is at risk for hyponatremia in addition to the hypercalcemia. Hypertonic solutions will not help facilitate the removal of calcium through the kidneys. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.4.3. Examine the diagnosis and treatment of a calcium imbalance. Page Number: 208
Question 33 Type: MCSA A 28-year-old male patient is admitted with diabetic ketoacidosis. Which electrolyte should the nurse expect to be replaced in this patient? 1. sodium 2. potassium 3. calcium 4. magnesium Correct Answer: 4 Rationale 1: The patient will not typically have an increased need for sodium. Rationale 2: The patient will not typically have an increased need for potassium. Rationale 3: The patient will not typically have an increased need for calcium.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis. Global Rationale: One risk factor for hypomagnesaemia is an endocrine disorder, including diabetic ketoacidosis. The patient’s levels of sodium, potassium, and calcium are not the primary needs of this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.5.3. Examine the diagnosis and treatment of a magnesium imbalance. Page Number: 209
Question 34 Type: MCSA An older patient with peripheral neuropathy has been taking magnesium supplements. The nurse realizes that which symptoms indicate hypermagnesemia? 1. hypotension, warmth, and sweating 2. nausea and vomiting 3. hyperreflexia 4. excessive urination Correct Answer: 1 Rationale 1: Elevations in magnesium levels are accompanied by hypotension, warmth, and sweating. Rationale 2: Lower levels of magnesium are associated with nausea and vomiting. Rationale 3: Lower levels of magnesium are associated and hyperreflexia. Rationale 4: Urinary changes are not noted.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Elevations in magnesium levels is accompanied by hypotension, warmth, and sweating. Lower levels are associated with nausea and vomiting, hypertension, and hyperreflexia. Urinary changes are not noted. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.5.3. Examine the diagnosis and treatment of a magnesium imbalance. Page Number: 211
Question 35 Type: MCSA A patient is admitted with burns over 50% of his body. The nurse realizes that this patient is at risk for which electrolyte imbalances? 1. hypercalcemia 2. hypophosphatemia 3. hypernatremia 4. hypermagnesemia Correct Answer: 2 Rationale 1: Patients who experience burns are not at an increased risk for developing increased blood calcium levels. Rationale 2: Causes of hypophosphatemia include stress responses and extensive burns. Rationale 3: Patients who experience burns are not at an increased risk for developing increased blood sodium levels. Rationale 4: Patients who experience burns are not at an increased risk for developing increased blood magnesium levels. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Causes of hypophosphatemia include stress responses and extensive burns. Patients who experience burns are not at an increased risk for elevated levels of calcium, sodium, or magnesium. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.6.1. Examine the causes and pathophysiology of a phosphorus imbalance. Page Number: 212
Question 36 Type: MCSA A patient is diagnosed with hyperphosphatemia. The nurse realizes that this patient might also have an imbalance of what electrolyte? 1. calcium 2. sodium 3. potassium 4. chloride Correct Answer: 1 Rationale 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. Rationale 2: There is no direct correlation between levels of phosphorus and that of sodium. Rationale 3: There is no direct correlation between levels of phosphorus and that of potassium. Rationale 4: There is no direct correlation between levels of phosphorus and that of chloride. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. There is no direct correlation between levels of phosphorus and that of sodium, potassium, or chloride. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.6.1. Examine the causes and pathophysiology of a phosphorus imbalance. Page Number: 212
Question 37 Type: MCMA The nurse is reviewing a patient’s blood pH level. What systems in the body does the nurse recognize as contributing to the regulation of blood pH? Standard Text: Select all that apply. 1. renal 2. cardiac 3. buffers 4. respiratory 5. integument Correct Answer: 1, 3, 4 Rationale 1: Three systems work together in the body to maintain the pH despite continuous acid production, and the renal system is one of them. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The cardiac system is responsible for circulating blood to the body. It does not help maintain the body’s pH. Rationale 3: Three systems work together in the body to maintain the pH despite continuous acid production, and the buffer system is one of them. Rationale 4: Three systems work together in the body to maintain the pH despite continuous acid production, and the respiratory system is one of them. Global Rationale: Three systems work together in the body to maintain the pH despite continuous acid production: buffers, the respiratory system, and the renal system. The cardiac system is responsible for circulating blood to the body. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.1. Apply nursing process as framework to provide nursing care to the client with respiratory acidosis. Page Number: 213
Question 38 Type: MCSA 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 Correct Answer: 2 Rationale 1: Hypernatremia is associated with profuse sweating and diarrhea. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 3: The respiratory rate in a patient exhibiting hypertension is not altered. Rationale 4: Pain may be manifested in rapid, shallow respirations. Global Rationale: 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. Hypernatremia is associated with profuse sweating and diarrhea. The respiratory rate in a patient exhibiting hypertension is not altered. Pain may be manifested in rapid, shallow respirations. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.3. Apply nursing process as framework to provide nursing care to the client with metabolic acidosis. Page Number: 213
Question 39 Type: MCSA The blood gases of a patient with an acid‒base disorder show a blood pH outside of normal limits. The nurse realizes that this patient is 1. fully compensated. 2. demonstrating anaerobic metabolism. 3. partially compensated. 4. in need of intravenous fluids. Correct Answer: 3 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: If the pH is restored to within normal limits, the disorder is said to be fully compensated. Rationale 2: Anaerobic metabolism results when the body’s cells become hypoxic. Rationale 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. Rationale 4: Although the patient may be in need of intravenous fluids, this is not the most correct or definitive answer. Global Rationale: 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. Anaerobic metabolism results when the body’s cells become hypoxic. Although the patient may be in need of intravenous fluids, this is not the most correct or definitive answer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.3. Apply nursing process as framework to provide nursing care to the client with metabolic acidosis. Page Number: 217
Question 40 Type: MCSA A patient’s blood gases show a pH of 7.53 and bicarbonate level of 36 mEq/L. The nurse realizes that the patient is demonstrating which acid‒base disorder? 1. respiratory acidosis 2. metabolic acidosis 3. respiratory alkalosis 4. metabolic alkalosis LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 4 Rationale 1: Respiratory acidosis and metabolic acidosis are both consistent with pH less than 7.35. Rationale 2: Respiratory acidosis and metabolic acidosis are both consistent with pH less than 7.35. Rationale 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. Rationale 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. Global Rationale: 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. Respiratory and metabolic acidosis are both consistent with pH less than 7.35. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.4. Apply nursing process as framework to provide nursing care to the client with metabolic alkalosis. Page Number: 221
Question 41 Type: MCSA An older postoperative patient is demonstrating lethargy, confusion, and a respiratory rate of 8 per minute. The nurse sees that the last dose of pain medication administered via a patient controlled anesthesia (PCA) pump was within 30 minutes. Which acid‒base disorder might this patient be experiencing? 1. respiratory acidosis 2. metabolic acidosis 3. respiratory alkalosis LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. metabolic alkalosis Correct Answer: 1 Rationale 1: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. Rationale 2: The patient condition being described is respiratory, not metabolic, in nature. Rationale 3: Respiratory alkalosis is characterized by anxiety with hyperventilation. Rationale 4: The patient condition being described is respiratory, not metabolic, in nature. Global Rationale: Acute respiratory acidosis occurs due to a sudden failure of ventilation. Overdoses of narcotic or sedative medications can lead to this condition. Respiratory alkalosis is characterized by anxiety with hyperventilation. The patient condition being described is respiratory, not metabolic, in nature. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.1. Apply nursing process as framework to provide nursing care to the client with respiratory acidosis. Page Number: 223
Question 42 Type: FIB A patient has been placed on 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? Standard Text: Correct Answer: 540 Rationale: 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 1200mL − 240 mL = 960mL). The LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 540 mL. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 191
Question 43 Type: MCHS The nurse is caring for a patient with serum potassium of 5.9 mEq/L. Which electrocardiogram tracing should the nurse expect to observe in this patient? Place an “X” on the tracing that is most likely to represent the patient’s cardiac electrical activity.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer:
Rationale: A serum potassium of 5.9 represents hyperkalemia. The ECG findings associated with hyperkalemia are prolongation of the PR interval, a wide QRS, ST segment depression, and a tall-tented T wave. Those findings are represented in the last of the ECG tracings. The first tracing is normal; the second tracing is representative of the changes noted in a patient with hypokalemia (ST segment depression, flattened T wave, and presence of a U wave). Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.2. Contrast the manifestations of a potassium imbalance. Page Number: 201
Question 44 Type: MCMA The patient is prescribed to receive intravenous potassium chloride (KCL). Which actions should the nurse take when administering this medication? Standard Text: Select all that apply. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 controller for the IV. 5. Monitor fluid intake and output. Correct Answer: 2, 4, 5 Rationale 1: KCL should be given via IV infusion, not IV push. Rationale 2: The nurse should monitor the injection site for redness. Rationale 3: KCL should not be added to the IV hanging. Rationale 4: The nurse should use an infusion controller for the IV infusion. Rationale 5: The nurse should monitor patient fluid intake and output. Global Rationale: KCL should be given via IV infusion, not IV push, and should not be added to the IV hanging. The nurse should monitor the injection site for redness, use an infusion controller for the IV infusion, and monitor patient fluid intake and output. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.2. Contrast the manifestations of a potassium imbalance. Page Number: 198
Question 45 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is reviewing care needs for a group of assigned patients. Which patients should the nurse identify as being at risk for the development of hypercalcemia? Standard Text: Select all that apply. 1. the patient with a malignancy 2. the patient taking lithium 3. the patient who uses sunscreen to excess 4. the patient with hyperparathyroidism 5. the patient who overuses antacids Correct Answer: 1, 2, 4, 5 Rationale 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. Rationale 2: Lithium can result in hypercalcemia. Rationale 3: The patient who uses sunscreen to excess is more likely to have a vitamin D deficiency, which would result in hypocalcemia. Rationale 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. Rationale 5: Overuse of antacids can result in hypercalcemia. Global Rationale: 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. Lithium and overuse of antacids can result in hypercalcemia. 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. The patient who uses sunscreen to excess is more likely to have a vitamin D deficiency, which would result in hypocalcemia. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.4.1. Examine the risk factors, causes, and pathophysiology of a calcium imbalance. Page Number: 207-208
Question 46 Type: MCMA The patient who has a serum magnesium level of 1.4 mg/dL is being treated with dietary modification. Which foods should the nurse suggest for this patient? Standard Text: Select all that apply. 1. romaine lettuce 2. seafood 3. white rice 4. lean red meat 5. almonds Correct Answer: 1, 2, 4, 5 Rationale 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. Rationale 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. Rationale 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. Rationale 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 meats. Rationale 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 nuts such as almonds. Global Rationale: Serum magnesium level of 1.4 mg/dL suggests mild hypomagnesaemia, so this patient should be counseled to eat foods high in magnesium. Foods high in magnesium include green leafy vegetables such as romaine, seafood, meats, and almonds, as well as other foods. White rice is not high in magnesium. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.5.3. Examine the diagnosis and treatment of a magnesium imbalance. Page Number: 209 Question 47 Type: MCMA A patient has a serum phosphate level of 4.7 mg/dL. Which treatments should the nurse expect to be prescribed for this patient? Standard Text: 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 Correct Answer: 1, 2 Rationale 1: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate. Rationale 2: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Calcium-containing antacids bind the phosphate for excretion through the GI tract. Rationale 3: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV potassium phosphate is a treatment for low phosphate
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Milk is a high phosphate food and should be discouraged. Rationale 5: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. Excess vitamin D increases phosphate absorption and can lead to hyperphosphatemia. Global Rationale: Serum phosphate level of 4.7 mg/dL indicates hyperphosphatemia. IV normal saline promotes renal excretion of phosphate. Calcium-containing antacids bind the phosphate for excretion through the GI tract. IV potassium phosphate is a treatment for low phosphate. Milk is a high phosphate food and should be discouraged. Excess vitamin D increases phosphate absorption and can lead to hyperphosphatemia. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.6.3. Examine the diagnosis and treatment of a phosphorus imbalance. Page Number: 212 Question 48 Type: MCMA A patient newly diagnosed with diabetes mellitus is admitted to the emergency department with nausea, vomiting, and abdominal pain. ABG results reveal a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment findings should the nurse anticipate in this patient? Standard Text: Select all that apply. 1. tachycardia 2. weakness 3. dysrhythmias 4. Kussmaul respirations 5. cold, clammy skin Correct Answer: 2, 3, 4 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. Further assessment findings of this condition are weakness; bradycardia; dysrhythmias; general malaise; decreased level of consciousness; warm, flushed skin; and Kussmaul respirations. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.3. Apply nursing process as framework to provide nursing care to the client with metabolic acidosis. Page Number: 219
Question 49 Type: FIB 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? Standard Text: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 11 mEq/L Rationale: 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. Global Rationale: 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the causes, effects, and management of acid–base imbalances. MNL Learning Outcome: 1.7.3. Apply nursing process as framework to provide nursing care to the client with metabolic acidosis. Page Number: 219
Question 50 Type: FIB 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? Standard Text: Correct Answer: 2400 mL Rationale: 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 kg or 30 mL/kg × 80 kg = 2400 mL. The nurse should instruct the patient to ingest 2400 mL of fluid per day. Global Rationale: 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 kg or 30 mL/kg × 80 kg = 2400 mL. The nurse should instruct the patient to ingest 2400 mL of fluid per day. Cognitive Level: Applying Client Need: Health Promotion and Maintenance LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the functions and regulatory mechanisms that maintain water, electrolyte, and acid–base balance in the body. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 185
Question 51 Type: MCMR 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? Standard Text: 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. Correct Answer: 1, 3, 4 Rationale 1: Teaching for the patient prescribed a diuretic should include expecting the medication to increase urination. Rationale 2: Weakness and dizziness are not expected and should be reported to the healthcare provider. Rationale 3: Teaching for the patient prescribed a diuretic should include measuring body weight every day. Rationale 4: Teaching for the patient prescribed a diuretic should include reporting swelling of the face or hands to the healthcare provider. Rationale 5: The medication should be taken in the morning or afternoon so that sleep is not interrupted to urinate. Global Rationale: Teaching for the patient prescribed a diuretic should include expecting the medication to increase urination, measuring body weight every day, and reporting swelling of the face or hands to the healthcare provider. Weakness and dizziness are not expected and should be reported to the healthcare provider. The medication should be taken in the morning or afternoon so that sleep is not interrupted to urinate. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 190 Question 52 Type: MCMR 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? Standard Text: Select all that apply. 1. insulin 2. dextrose 10% 3. furosemide (Lasix) 4. sodium bicarbonate 5. sodium polystyrene sulfonate (Kayexalate) Correct Answer: 1, 2, 4 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Rationale 5: Sodium polystyrene sulfonate (Kayexalate) is used to treat moderate or severe hyperkalemia.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Insulin, hypertonic dextrose (10% to 50%), and possibly sodium bicarbonate are 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, and glucose prevents hypoglycemia. Sodium bicarbonate elevates the serum pH; potassium is moved into the cell in exchange for hydrogen ion. Sodium polystyrene sulfonate (Kayexalate) is used to treat moderate or severe hyperkalemia. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.3.3. Distinguish the diagnosis and treatment of a potassium imbalance. Page Number: 203
Question 53 Type: MCMR The nurse is concerned that a patient recovering from a thyroidectomy is developing hypocalcemia. What findings did the nurse use to come to this conclusion? Standard Text: 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 Correct Answer: 2, 3, 4, 5 Rationale 1: Hypocalcemia causes bradycardia. A regular heart rate of 88 is within normal limits. Rationale 2: Manifestations of hypocalcemia include numbness and tingling in the hands. Rationale 3: Muscle spasms of the face occur such as Chvostek sign, which is the contraction of the facial muscles. Rationale 4: Manifestations of hypocalcemia include numbness and tingling in the hands and feet. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Trousseau sign, a carpal spasm induced by inflating a blood pressure cuff, occurs with hypocalcemia. Global Rationale: Manifestations of hypocalcemia include numbness and tingling around the mouth and in the hands and feet. Muscle spasms of the face such as the Chvostek sign, which is the contraction of the facial muscles, and Trousseau sign, which is a carpal spasm induced by inflating a blood pressure cuff, also occur. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the causes, pathophysiology, effects, and care of the patient with fluid volume or electrolyte imbalance. MNL Learning Outcome: 1.4.2. Explain the manifestations and complications of a calcium imbalance. Page Number: 205
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 11 Question 1 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: There is insufficient information to determine whether the patient was wearing a seat restraint. Rationale 3: There is insufficient information to determine whether the accident was caused by a drunk driver. Rationale 4: There is insufficient information to determine whether the patient was paying attention while driving. Global Rationale: 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. There is insufficient information to determine whether the patient was wearing a seat restraint, the patient was not paying attention while driving, or the accident was caused by a drunk driver. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Define the word trauma. MNL Learning Outcome: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 230 Question 2 Type: MCSA The spouse of a patient admitted with a gunshot wound asks the nurse when her husband will be discharged so that they can resume their life together. How should the nurse respond? 1. “Right now there is no way of knowing how soon your husband can return to his previous life.” 2. “I would say in a few weeks.” 3. “Probably never.” 4. “As soon as the wound heals, your husband can return to work.” Correct Answer: 1 Rationale 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 to his previous life. Rationale 2: The nurse should not put a time limit of a few weeks on the patient’s recovery from trauma. Rationale 3: The nurse should not tell the spouse that the patient will probably never return to his previous life. Rationale 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. Global Rationale: 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 to his previous life. The nurse should not put a time limit of a few weeks on the patient’s recovery from trauma or tell the spouse that the patient will probably never return to his previous life. 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. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 1. Define the word trauma. MNL Learning Outcome: Page Number: 230 Question 3 Type: MCMA An older patient is admitted after falling on the steps at home. Which components of trauma should the nurse consider when planning care for the patient? Standard Text: Select all that apply. 1. host 2. environment 3. intention 4. source 5. transmission Correct Answer: 1, 2, 3 Rationale 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. Rationale 2: The environment in which the trauma occurred needs to be taken into consideration. Rationale 3: The event was either intentional or unintentional. As the patient fell on the steps at home, the event was most likely unintentional. Rationale 4: Source is not a component of a traumatic event. Rationale 5: Transmission is not a component of a traumatic event. Global Rationale: 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. The environment in which the trauma occurred needs to be taken into consideration. As the patient fell on LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
the steps at home, the event was most likely unintentional. Source and transmission are not components of a traumatic event. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 2. Define the components and types of trauma. MNL Learning Outcome: 8.1.1. Explain the pathophysiology of traumatic musculoskeletal injuries. Page Number: 230 Question 4 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures. Rationale 4: Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Class 1 trauma involves lifethreatening 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. Penetrating trauma occurs when a foreign object enters the body, causing damage to body structures. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 2. Define the components and types of trauma. MNL Learning Outcome: 8.1.1. Explain the pathophysiology of traumatic musculoskeletal injuries. Page Number: 231 Question 5 Type: MCSA A patient is brought to the emergency department with injuries sustained when a wall collapsed in the home. The nurse recognizes that this patient’s injuries were most likely caused by which mechanism of injury? 1. crushing 2. shearing 3. deceleration 4. blast Correct Answer: 1 Rationale 1: A crushing injury occurs from a high force that leads to tissue destruction. The collapsing wall most likely caused crushing injuries. Rationale 2: Shearing occurs when structures slip across each other. Rationale 3: Deceleration is the decrease in speed of a moving object.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Global Rationale: A crushing injury occurs from a high force that leads to tissue destruction. The collapsing wall most likely caused crushing injuries. Shearing occurs when structures slip across each other. Deceleration is the decrease in speed of a moving object. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Define the components and types of trauma. MNL Learning Outcome: 8.1.1. Explain the pathophysiology of traumatic musculoskeletal injuries. Page Number: 231 Question 6 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Shearing occurs when structures slip across each other. Rationale 3: Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Global Rationale: 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. Shearing occurs when structures slip across each other. Blast injuries result from the temperature and velocity of air movement and the force of projectiles from the explosion. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Define the components and types of trauma. MNL Learning Outcome: 7.4.1. Explain the causes and pathophysiology of traumatic brain injuries. Page Number: 230 Question 7 Type: MCSA A patient is admitted with a thermal injury. Which mechanism of injury should the nurse consider as the most likely cause of this patient’s injuries? 1. fire 2. lightning 3. ultraviolet radiation 4. gunshot Correct Answer: 1 Rationale 1: The energy source for the patient’s injury is thermal. Mechanisms of injury for thermal injuries include fire, heating appliances, and freezing temperatures. Rationale 2: The energy source for lightning is electrical. Rationale 3: The energy source for ultraviolet radiation is physical.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The energy source for a gunshot is mechanical. Global Rationale: The energy source for the patient’s injury is thermal. Mechanisms of injury for thermal injuries include fire, heating appliances, and freezing temperatures. The energy source for lightning is electrical. The energy source for ultraviolet radiation is physical. The energy source for a gunshot is mechanical. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the result of energy transfer to the human body. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 230 Question 8 Type: MCSA A pediatric patient is admitted after ingesting a household cleaning solution. The nurse should plan care for this patient’s injuries based on which energy source? 1. chemical 2. physical 3. thermal 4. mechanical Correct Answer: 1 Rationale 1: The energy source for drugs, poisons, and industrial chemicals is chemical. Rationale 2: The energy source for physical assault, drowning, or explosions is physical. Rationale 3: The energy source for heating appliances, fire, or freezing temperatures is thermal. Rationale 4: The energy source for motor vehicle accidents is mechanical. Global Rationale: The energy source for drugs, poisons, and industrial chemicals is chemical. The energy source for physical assault, drowning, or explosions would be physical; for heating appliances, fire, or freezing temperatures, thermal; and for motor vehicle accidents, mechanical. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 3. Describe the result of energy transfer to the human body. MNL Learning Outcome: 11.2.1. Explain the pathophysiology of mouth and esophagus disorders. Page Number: 230 Question 9 Type: MCSA A patient recovering from a motor vehicle accident tells the nurse that the other car “barely” hit him and asks why he has so many injuries. 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.” Correct Answer: 1 Rationale 1: The nurse should explain the transfer of energy to the patient’s body that caused the injuries. Rationale 2: Referring to other health problems identifies characteristics of the host but does not explain the number or types of injuries. Rationale 3: This response addresses the intention of the trauma but does not explain the number or types of injuries. Rationale 4: Referring to the patient’s age identifies characteristics of the host but does not explain the number or types of injuries. Global Rationale: The nurse should explain the transfer of energy to the patient’s body that caused the injuries. Referring to the patient’s other health problems and age identifies characteristics of the host but does not explain the number or types of injuries. The response that the driver of the other car intended to injure the patient addresses the intention of the trauma but does not explain the number or types of injuries. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 3. Describe the result of energy transfer to the human body. MNL Learning Outcome: 8.1.1. Explain the pathophysiology of traumatic musculoskeletal injuries. Page Number: 230 Question 10 Type: MCSA A construction worker was admitted after falling from the roof of a building. The nurse should plan care for this patient’s injuries based on which energy source? 1. gravitational 2. mechanical 3. physical 4. electrical Correct Answer: 1 Rationale 1: The energy source for a fall is gravitational. Rationale 2: The energy source for motor vehicle accidents is mechanical. Rationale 3: The energy source for physical assaults, explosions, and drowning is physical. Rationale 4: The energy source for lightning is electrical. Global Rationale: The energy source for a fall is gravity. The energy source for motor vehicle accidents is mechanical. The energy source for physical assaults, explosions, and drowning is physical. The energy source for lightning is electrical. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Describe the result of energy transfer to the human body. MNL Learning Outcome: 8.1.1. Explain the pathophysiology of traumatic musculoskeletal injuries. Page Number: 230 Question 11 Type: MCSA A patient is admitted to the hospital with injuries from a motor vehicle crash. During the nurse’s initial assessment, the patient 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 Correct Answer: 1 Rationale 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. Rationale 2: The patient would not have jugular vein distention with a hemorrhage. Rationale 3: The patient would not have jugular vein distention with compensatory shock. Rationale 4: The patient would not have jugular vein distention with hypovolemic shock. Global Rationale: 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. The patient would not have jugular vein distention with a hemorrhage, compensatory shock, or hypovolemic shock. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 5.6.2. Differentiate the manifestations of trauma of the chest, lungs, and supporting structures. Page Number: 232 Question 12 Type: MCSA A patient is admitted with a diagnosis of blunt trauma to the abdomen after a motor vehicle crash. What should the nurse assess first when the patient arrives in the emergency department? 1. airway for patency 2. abdomen for any abnormalities 3. cervical spine for tenderness 4. signs of neurological deficits Correct Answer: 1 Rationale 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, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the patient is responsive and can vocalize, that is a good indication that the airway is clear. Rationale 2: Another assessment must take place initially. Rationale 3: Another assessment must take place initially. Rationale 4: The nurse is always concerned about the neurological assessment of a patient, but this patient has a blunt trauma injury from a motor vehicle crash; therefore, this would not be the initial assessment. Global Rationale: 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, the practitioner must identify any potential obstruction from the tongue, loose teeth, foreign bodies, bleeding, secretions, vomitus, or edema. If the patient is responsive and can vocalize, that is a good indication that the airway is clear. All the other responses are important, but certainly the nurse should address the airway initially. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 5.6.2. Differentiate the manifestations of trauma of the chest, lungs, and supporting structures. Page Number: 232 Question 13 Type: MCSA A patient is brought to the emergency department with a penetrating wound to the neck. The patient is dyspneic and cyanotic and has evidence of subcutaneous emphysema. What does the nurse expect the physician to do initially? 1. intubate the patient because of the severe wound 2. notify the next of kin regarding the patient’s condition 3. order x-rays of the lumbar area to assess for fractures 4. administer a beta blocker to alleviate the sympathetic response Correct Answer: 1 Rationale 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. Rationale 2: Another action is more critical initially. Rationale 3: Another action is more critical initially. Rationale 4: Another action is more critical initially. Global Rationale: 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. The physician will most likely do or prescribe the other options; however, the most important is to maintain the airway. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 5.6.2. Differentiate the manifestations of trauma of the chest, lungs, and supporting structures. Page Number: 232 Question 14 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: A lack of motor response would be an indication of a cervical spine injury. Rationale 3: A lack of deep tendon reflexes would be an indication of a cervical spine injury. Rationale 4: Lethargy and confusion would be indications of a cervical spine injury. Global Rationale: 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. A lack of motor response, lack of deep tendon reflexes, and the presence of lethargy and confusion would be indications of a cervical spine injury. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 7.6.2. Differentiate the manifestations of spinal cord disorders. Page Number: 232 Question 15 Type: MCSA A patient is brought to the emergency department with physical injuries sustained in a gang fight. The patient’s blood pressure is 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 Correct Answer: 1 Rationale 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. Rationale 2: A complete blood count would not provide the fastest information for this patient. Rationale 3: A urinalysis would not provide the fastest information for this patient. Rationale 4: Serum electrolyte levels would not provide the fastest information for this patient. Global Rationale: 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. A complete blood count, urinalysis, and serum electrolyte levels would not provide the fastest information for this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Discuss diagnostic tests used in assessing patients experiencing trauma and shock. MNL Learning Outcome: 11.15.3. Examine the diagnosis and treatment of abdominal trauma. Page Number: 236 Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 1: Magnetic resonance imaging scans reveal injuries to the brain and spinal cord. Rationale 2: Cervical spine x-rays can detect fractures of the vertebrae but not injuries to the brain. Rationale 3: Spinal cord x-rays can detect fractures of the vertebrae but not injuries to the brain. Rationale 4: A cerebral angiogram can detect injuries to the brain but not to the spinal cord. Global Rationale: Magnetic resonance imaging scans reveal injuries to the brain and spinal cord. Cervical spine and spinal cord x-rays can detect fractures of the vertebrae but not injuries to the brain. A cerebral angiogram can detect injuries to the brain but not to the spinal cord. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss diagnostic tests used in assessing patients experiencing trauma and shock. MNL Learning Outcome: 7.4.3. Examine the diagnosis and treatment of traumatic brain injuries. Page Number: 237 Question 17 Type: MCMA A victim of a multivehicle automobile crash is brought into the emergency department. The patient has slurred speech and is lethargic. The nurse anticipates that which diagnostic tests would be indicated for this patient? Standard Text: Select all that apply. 1. blood alcohol level 2. urine drug screen 3. skull x-rays 4. chest x-ray 5. urinalysis Correct Answer: 1, 2 Rationale 1: Alcohol alters a person’s level of consciousness, so a blood alcohol level would likely be ordered for a patient with slurred speech and lethargy. Rationale 2: Some drugs can cause lethargy and slurred speech. A urine drug screen would likely be ordered for this patient. Rationale 3: This diagnostic test may or may not be indicated for the patient. Rationale 4: A chest x-ray would likely be ordered, but not because of the slurred speech or lethargy. Rationale 5: Urinalysis will most likely be done however not because of slurred speech or lethargy. Global Rationale: Alcohol alters a person’s level of consciousness, so a blood alcohol level would likely be ordered for a patient with slurred speech and lethargy. Some drugs can cause lethargy and slurred speech, so a urine drug screen would likely be ordered for this patient. Skull x-rays may or may not be indicated for the patient. A chest x-ray and urinalysis would likely be ordered, but not because of the slurred speech or lethargy. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Discuss diagnostic tests used in assessing patients experiencing trauma and shock. MNL Learning Outcome: 7.4.3. Examine the diagnosis and treatment of traumatic brain injuries. Page Number: 236 Question 18 Type: MCSA The nurse determines that a patient is experiencing ongoing progression of a shock state. What finding led 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 Correct Answer: 1 Rationale 1: Serum electrolyte levels are assessed to monitor the severity and progression of shock. As shock progresses, serum glucose levels decrease. Rationale 2: A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow. Rationale 3: An increase in eosinophils indicates an allergic response. Rationale 4: Low serum cardiac enzymes indicate there is no myocardial damage. Global Rationale: Serum electrolyte levels are assessed to monitor the severity and progression of shock. As shock progresses, serum glucose levels decrease. A drop in blood urea nitrogen level means the kidneys are receiving adequate blood flow. An increase in eosinophils indicates an allergic response. Low serum cardiac enzymes indicate there is no myocardial damage. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss diagnostic tests used in assessing patients experiencing trauma and shock. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 247 Question 19 Type: MCSA A patient with multiple traumatic injuries has experienced severe blood loss and is prescribed to receive blood immediately. The nurse realizes that because there is not enough time for type and crossmatch, the patient will most likely receive which type of blood? 1. O 2. A 3. B 4. AB Correct Answer: 1 Rationale 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 anti-B. Rationale 2: The person with blood type A has B antibodies. Rationale 3: The person with blood type B has A antibodies. Rationale 4: The person with AB has no antibodies (called a universal recipient). Global Rationale: 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 anti-B. The person with blood type B has A antibodies, the person with type A has B antibodies, the person with type O has both types of antibodies, and the person with AB has no antibodies (called a universal recipient). Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 237 Question 20 Type: MCSA A patient with multiple gunshot wounds to the abdomen has received 8 units of blood. The blood bank notifies the nurse that they have run out of blood for the patient. The nurse knows the patient can receive any type of blood if the patient has which blood type? 1. AB 2. A 3. B 4. O Correct Answer: 1 Rationale 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. Rationale 2: The person with blood type A has B antibodies. Rationale 3: The person with type B has A antibodies. Rationale 4: A person with the O blood type has both A and B antibodies and is considered a universal donor in an emergency situation. Global Rationale: The person with blood type A has B antibodies, someone with type B has A antibodies, someone with type AB has no antibodies, and someone with type O has both A and B antibodies. Therefore, the person with type AB blood can receive any type of blood in an emergency and is referred to as a universal recipient. A person with blood type O is considered a universal donor. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 237 Question 21 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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 interstit ial space. Rationale 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. Rationale 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. Global Rationale: 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. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 253 Question 22 Type: MCSA A patient diagnosed with hypovolemic shock is prescribed intravenous fluids while awaiting blood transfusions. Which solution does 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 Correct Answer: 1 Rationale 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. Rationale 2: Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Rationale 3: Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Rationale 4: Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Global Rationale: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
solutions may be infused rapidly, increasing blood volume and tissue perfusion. Hypotonic crystalloid solutions, such as dextrose 5% in water or normal saline, increase fluid volume in both the intravascular and interstitial spaces. But approximately 25% of the fluid stays within the intravascular space, increasing the risk of peripheral edema. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 238 Question 23 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: This medication will not reduce the heart rate. Rationale 3: This medication will not reduce the respiratory rate. Rationale 4: This medication will not reduce the blood pressure.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. This medication will not reduce the heart rate, respiratory rate, or blood pressure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 253 Question 24 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: This medication must be used within 4 hours of reconstitution. Rationale 4: The patient receiving intravenous nitroglycerin should be on bed rest, not assisted out of bed.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Intravenous nitroglycerin must be mixed in glass bottles and infused through special, nonPVC tubing, because up to 40%–80% of nitroglycerin can be absorbed by PVC bags or tubing. This medication must be infused with an infusion pump and used within 4 hours of reconstitution. The patient receiving intravenous nitroglycerin should be on bed rest, not assisted out of bed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 253 Question 25 Type: MCMA A patient with a traumatic brain injury is being evaluated for brain death. Which findings should the nurse expect in this patient? Standard Text: 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 Correct Answer: 1,2,3 Rationale 1: An absence of the gag or corneal reflex is a clinical sign that is consistent with brain death. Rationale 2: An absence of the oculovestibular reflex is a clinical sign that is consistent with brain death. Rationale 3: Apnea with PaCO2 of 66 mmHg is a clinical sign that is consistent with brain death. Rationale 4: Toxic metabolic disorders are not consistent with brain death. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Responding to deep stimuli is not a sign consistent with brain death. Global Rationale: An absence of gag or corneal reflex, an absence of oculovestibular reflex, and apnea with PaCO2 of 66 mmHg are clinical signs consistent with brain death. Toxic metabolic disorders and responding to deep stimuli are not signs consistent with brain death. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Discuss organ donation and forensic implications of traumatic injury or death. MNL Learning Outcome: 7.4.3. Examine the diagnosis and treatment of traumatic brain injuries. Page Number: 239 Question 26 Type: MCSA The spouse of a patient admitted with severe head injury tells the nurse that she believes her husband is going to recover because he is continuing to make 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 husband will likely recover in time.” 3. “As long as he has oxygen to the brain, he will recover.” 4. “His movements indicate that his brain is dead.” Correct Answer: 1 Rationale 1: One criterion of brain death is the lack of spontaneous movement; however, some spinal cord reflexes may be present. Rationale 2: The nurse should not tell the spouse that the patient will recover in time. Rationale 3: The nurse should not tell the spouse that the patient will recover as long as he has oxygen to the brain.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The patient has a brain injury; his movements are likely spinal cord reflexes rather than spontaneous movements. Additional testing must be done before brain death is diagnosed. Global Rationale: One criterion of brain death is the lack of spontaneous movement; however, some spinal cord reflexes may be present. The nurse should not tell the spouse that the patient will recover in time or will recover as long as he has oxygen to the brain. The patient has a brain injury; his movements are likely spinal cord reflexes rather than spontaneous movements. Additional testing must be done before brain death is diagnosed. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Discuss organ donation and forensic implications of traumatic injury or death. MNL Learning Outcome: 7.4.3. Examine the diagnosis and treatment of traumatic brain injuries. Page Number: 239 Question 27 Type: MCSA 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. Correct Answer: 1 Rationale 1: Each item of clothing removed from the patient must be placed in a breathable container, such as a paper bag, and documented appropriately. Rationale 2: The patient’s hands should be covered with paper bags only if the patient died. Rationale 3: The clothing should not be cut off in order to bathe the patient’s skin and wounds.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Global Rationale: Each item of clothing removed from the patient must be placed in a breathable container, such as a paper bag, and documented appropriately. The clothing should not be cut off in order to bathe the patient’s skin and wounds. 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. The patient’s hands should be covered with paper bags only if the patient died. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essentials Competencies: V.6. Explore the impact of socio-cultural, 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: 7. Discuss organ donation and forensic implications of traumatic injury or death. MNL Learning Outcome: 11.15.3. Examine the diagnosis and treatment of abdominal trauma. Page Number: 239 Question 28 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: The oxygen saturation level needs to be kept at 90% or greater. Rationale 3: Medications and fluids are provided to keep urine output at more than 30 mL per hour. Rationale 4: External cardiac compressions should not be performed. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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, maintain urine output at more than 30 mL per hour, and maintain oxygen saturation at 90% or greater. External cardiac compressions should not be performed. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Management of Care QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team AACN Essentials Competencies: V.6. Explore the impact of socio-cultural, 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: 7. Discuss organ donation and forensic implications of traumatic injury or death. MNL Learning Outcome: 6.4.3. Examine the treatment options for cardiac perfusion disorders. Page Number: 239 Question 29 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Nonpalpable peripheral pulses are a sign of progressive shock. The patient is not in progressive shock. Rationale 3: Narrowing pulse pressure is a sign of progressive shock. The patient is not in progressive shock. Rationale 4: An increase in blood glucose level is a sign of progressive shock. The patient is not in progressive shock. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Nonpalpable peripheral pulses, narrowing pulse pressure, and an increase in blood glucose level are all seen in progressive shock. The patient is not in progressive shock. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 8. Discuss cellular homeostasis and basic hemodynamics. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 244-245 Question 30 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Temperature is not used to calculate mean arterial pressure. Rationale 3: Respiratory rate is not used to calculate mean arterial pressure. Rationale 4: Heart rate is not used to calculate mean arterial pressure.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. The patient’s blood pressure is needed to make this calculation. Temperature, respirations, and heart rate are not used to calculate mean arterial pressure. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 8. Discuss cellular homeostasis and basic hemodynamics. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 244 Question 31 Type: MCSA 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. 2. Mean arterial pressure reaches 90. 3. Blood pressure reaches 120/80 mmHg. 4. Urine output is 10 mL per hour. Correct Answer: 1 Rationale 1: A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys. Rationale 2: A mean arterial pressure of 90 mmHg is considered within normal limits. Rationale 3: A blood pressure of 120/80 mmHg is considered normal. Rationale 4: A urine output of 10 mL per hour would not indicate adequate renal perfusion. Global Rationale: A mean arterial pressure of 60 mmHg is required to maintain adequate perfusion to the brain, heart, and kidneys. A mean arterial pressure of 90 is considered within normal limits. A blood pressure of 120/80 mmHg is considered normal. A urine output of 10 mL per hour would not indicate adequate renal perfusion. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Evaluation Learning Outcome: 8. Discuss cellular homeostasis and basic hemodynamics. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 244 Question 32 Type: MCSA A patient has an estimated blood loss of 2 liters 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 Correct Answer: 1 Rationale 1: With a blood loss of 2 liters 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. Rationale 2: As this process continues, the cells swell, not shrink. Rationale 3: Peripheral pulses may not be palpable. Rationale 4: The body develops acidosis, not alkalosis. Global Rationale: With a blood loss of two liters 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. As this process continues, the cells swell, not shrink. Peripheral pulses may not be palpable. The body develops acidosis, not alkalosis. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 8. Discuss cellular homeostasis and basic hemodynamics. MNL Learning Outcome: 1.1.1. Examine the pathophysiology of fluid imbalances. Page Number: 245 Question 33 Type: MCSA The nurse, caring for a patient who sustained a traumatic injury several days ago, notes that the patient is hypotensive, oliguric, and has cool, pale skin and acidosis. The nurse understands that these are manifestations of which type of shock? 1. hypovolemic 2. cardiogenic 3. septic 4. anaphylactic Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 4: Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Cardiogenic shock occurs when the heart’s pumping ability is compromised to the point that it cannot maintain cardiac output and adequate tissue perfusion. 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. Anaphylactic shock is the result of a widespread hypersensitivity reaction from medications, blood administration, latex, foods, snake venom, and insect stings. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 9. Discuss the risk factors, etiologies, and pathophysiology of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 248 Question 34 Type: MCSA The nurse suspects that a patient diagnosed 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 Correct Answer: 1 Rationale 1: Jugular vein distention is seen in cardiogenic shock. Rationale 2: Warm extremities are seen in early septic shock and anaphylactic shock. Rationale 3: Laryngospasm is seen in anaphylactic shock. Rationale 4: Urticaria is seen in anaphylactic shock. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Jugular vein distention is seen in cardiogenic shock. Warm extremities are seen in early septic shock and anaphylactic shock. Laryngospasm and urticaria are seen in anaphylactic shock. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 9. Discuss the risk factors, etiologies, and pathophysiology of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock. MNL Learning Outcome: 6.4.2. Differentiate the risk factors and diagnostic tests for cardiac perfusion disorders. Page Number: 249 Question 35 Type: MCSA A patient is diagnosed with a pneumothorax. The nurse realizes that unless this is treated, the patient is at risk for developing which type of shock? 1. obstructive 2. hypovolemic 3. cardiogenic 4. neurogenic Correct Answer: 1 Rationale 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. Rationale 2: Hypovolemic shock is seen in patients with a low circulating blood volume. Rationale 3: Cardiogenic shock can occur in patients who have experienced a myocardial infarction. Rationale 4: Neurogenic shock can occur in patients with spinal cord injuries. Global Rationale: 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. Hypovolemic shock is seen in patients with a low circulating blood volume. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cardiogenic shock can occur in patients who have experienced a myocardial infarction. Neurogenic shock can occur in patients with spinal cord injuries. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 9. Discuss the risk factors, etiologies, and pathophysiology of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock. MNL Learning Outcome: 5.6.2. Differentiate the manifestations of trauma of the chest, lungs, and supporting structures. Page Number: 249 Question 36 Type: MCSA An older patient is diagnosed with E. coli in the bloodstream. If not treated, the nurse realizes this patient is at risk for developing which types of shock? 1. distributive 2. obstructive 3. hypovolemic 4. anaphylactic Correct Answer: 1 Rationale 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 one part of a progressive syndrome called systemic inflammatory response syndrome and is most often the result of gram-negative bacterial infections such as E. coli. Rationale 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. Rationale 3: Hypovolemic shock occurs with a decrease in circulating blood volume. Rationale 4: Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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 one part of a progressive syndrome called systemic inflammatory response syndrome and is most often the result of gram-negative bacterial infections such as E. coli. Obstructive shock is caused by an obstruction in the heart or great vessels that either impedes venous return or prevents effective cardiac pumping action. Hypovolemic shock occurs with a decrease in circulating blood volume. Anaphylactic shock occurs as the result of a widespread humorally mediated hypersensitivity reaction. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 9. Discuss the risk factors, etiologies, and pathophysiology of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock. MNL Learning Outcome: 11.9.1. Explain the pathophysiology of acute inflammatory and infectious disorders of the bowel. Page Number: 249 Question 37 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The blood pressure can be assessed after the patient is assessed for respiratory distress. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: The need for suctioning can be determined after it has been determined that the patient has an adequate airway. Rationale 4: Assessment of the mouth can occur after determining that the patient has an adequate airway. Global Rationale: 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 and cyanosis, dyspnea, decreased or absent breath sounds, changes in oxygen levels, and changes in level of consciousness. After it has been determined that the airway is adequate, the blood pressure and mouth can be assessed and the need for suctioning determined. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 5.6.4. Utilize the nursing process in care of client. Page Number: 241 Question 38 Type: MCSA A female who was a victim of rape 6 months ago comes to an outpatient clinic for the treatment of posttraumatic stress disorder. Which data collected during the patient’s assessment indicates a manifestation associated with this disorder? 1. The patient described severe nightmares related to the event. 2. The patient denied anger or shock. 3. The patient denied the need for drug or alcohol counseling. 4. The patient stated that her family is very supportive. Correct Answer: 1 Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Rationale 2: Feelings of anger and shock are associated with posttraumatic stress disorder. Rationale 3: Patients who suffer from posttraumatic stress disorder are more prone to using alcohol or drugs. Rationale 4: These patients usually withdraw from relationships. Global Rationale: 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. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 13.4.4. Utilize the nursing process in care of client. Page Number: 241 Question 39 Type: MCSA 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 Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. Rationale 3: Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. Rationale 4: Assessing bowel sounds would be appropriate for a problem with cardiac output. Global Rationale: 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. Assessing blood pressure and heart rate would be appropriate for a problem with cardiac output. Monitoring central venous pressure would be appropriate for a problem with tissue perfusion. Assessing bowel sounds would be appropriatefor a problem with cardiac output. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 241 Question 40 Type: MCSA 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. Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: The patient with impaired physical mobility should have active range-of-motion exercises to the affected extremities once every 8 hours. Rationale 2: The patient should be turned and repositioned every 2 hours. Rationale 3: Anti-embolic stockings should be removed for 1 hour every shift. Rationale 4: Administering the tetanus toxoid would be appropriate for reducing the risk for infection. Global Rationale: The patient with impaired physical mobility should have active range-of-motion exercises to the affected extremities once every 8 hours. The patient should be turned and repositioned every 2 hours. Antiembolic stockings should be removed for 1 hour every shift. Administering the tetanus toxoid would be appropriate for reducing the risk for infection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 8.1.4. Utilize the nursing process in care of client. Page Number: 242 Question 41 Type: MCMA A patient is admitted with trauma to the integumentary system. Which type of skin trauma should the nurse prepare to assess? Standard Text: Select all that apply. 1. cutaneous 2. abrasion 3. laceration 4. contusion 5. keloid
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2, 3, 4 Rationale 1: Cutaneous is a term used to refer to the integument, not to trauma to the skin. Rationale 2: Abrasions, or partial-thickness denudations of an area of integument, generally result from falls or scrapes. Rationale 3: Lacerations are open wounds that result from sharp cutting or tearing. Rationale 4: Contusions, or superficial tissue injuries, result from blunt trauma that causes the breakage of small blood vessels and bleeding into the surrounding tissue. Rationale 5: A keloid is a type of scar. Global Rationale: Abrasions, or partial-thickness denudations of an area of integument, generally result from falls or scrapes. Lacerations are open wounds that result from sharp cutting or tearing. Contusions, or superficial tissue injuries, result from blunt trauma that causes the breakage of small blood vessels and bleeding into the surrounding tissue. Cutaneous is a term used to refer to the integument, not to trauma to the skin. A keloid is a type of scar. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Define the components and types of trauma. MNL Learning Outcome: 4.1.2. Differentiate the manifestations of inflammatory and infectious skin disorders. Page Number: 234 Question 42 Type: MCMA A trauma patient is being assessed with the Champion Revised Scoring System. What assessment data should the nurse use with this scoring system? Standard Text: Select all that apply. 1. diastolic blood pressure 2. heart rate 3. Glasgow coma scale LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. systolic blood pressure 5. respiratory rate Correct Answer: 3, 4, 5 Rationale 1: Diastolic blood pressure is not included in the Champion Revised Scoring System. Rationale 2: Heart rate is not included in the Champion Revised Scoring System. Rationale 3: The Champion Revised Scoring System analyzes three elements, including the Glasgow Coma Scale. The patient receives a total score; the highest score is 12. Rationale 4: The Champion Revised Scoring System analyzes three elements, including the systolic blood pressure. The patient receives a total score; the highest score is 12. Rationale 5: The Champion Revised Scoring System analyzes three elements, including respiratory rate. The patient receives a total score; the highest score is 12. Global Rationale: The Champion Revised Scoring System analyzes three elements: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The patient receives a total score; the highest score is 12. Although the diastolic blood pressure and heart rate are part of the patient’s assessment, they are not included in the Champion Revised Scoring System. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 7.4.4. Utilize the nursing process in care of client. Page Number: 235 Question 43 Type: MCHS A patient comes to the emergency department with bright red blood flowing from the lower right arm. Place an “X” over the artery over which pressure would be applied to control the bleeding.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Direct pressure should be applied over the artery supplying the lower arm. The radial artery is not appropriate as it is in the lower arm and is affected by the trauma. No other arterial pressure point will control the bleeding of the lower arm. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 6.4.4. Utilize the nursing process in care of client. Page Number: 233 Question 44 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCHS During shock, the reticuloendothelial Kupffer cells can be destroyed. In which organ should the nurse identify the location of these cells? Place an “X” on the location of these cells.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: During shock, the blood supply to the liver is impaired because of constriction of the blood supply to the liver. The Kupffer cells (phagocytes that destroy bacteria) are destroyed, and bacteria can proliferate. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 9. Discuss the risk factors, etiologies, and pathophysiology of hypovolemic shock, cardiogenic shock, obstructive shock, and distributive shock. MNL Learning Outcome: 11.5.1. Explain the incidence and pathophysiology of liver disorders. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 247 Question 45 Type: MCSA The nurse is reviewing data for a patient experiencing shock. Based on these data, the nurse recognizes that the patient is in which stage of shock?
1. compensatory 2. early, reversible 3. progressive 4. refractory Correct Answer: 3 Rationale 1: In compensatory shock, the blood loss is 750 mL, with up to 15% blood volume loss. Other indicators are normal or increased; the patient is only slightly anxious. Rationale 2: In early reversible shock there is a blood loss of 750–1500 mL, 15%–30% blood volume loss, heart rate >100, blood pressure normal, pulse pressure decreased, capillary refill and respiratory rate slightly increased, urine output 20–30 mL/h. The patient is mildly anxious to agitated. Rationale 3: The manifestations in progressive shock are: blood loss of 1500–2000 mL, 30%–40% blood volume loss, heart rate >120, blood pressure and pulse pressure decreased, capillary refill increased over normal, moderate tachypnea, urinary output below normal, and mental status altered. Rationale 4: In refractory shock, the patient’s condition has deteriorated markedly, with over 2,000 mL blood loss and >40% loss of blood volume. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: In compensatory shock, the blood loss is 750 mL, with up to 15% blood volume loss. Other indicators are normal or increased; the patient is only slightly anxious. In early reversible shock there is a blood loss of 750–1500 mL, 15%–30% blood volume loss, heart rate >100, blood pressure normal, pulse pressure decreased, capillary refill and respiratory rate slightly increased, urine output 20–30 mL/h. The patient is mildly anxious to agitated. The manifestations in progressive shock are: blood loss of 1500–2000 mL, 30%–40% blood volume loss, heart rate >120, blood pressure and pulse pressure decreased, capillary refill increased over normal, moderate tachypnea, urinary output below normal, and mental status altered. In refractory shock, the patient’s condition has deteriorated markedly, with over 2,000 mL blood loss and >40% loss of blood volume. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 8. Discuss cellular homeostasis and basic hemodynamics. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 244-247 Question 46 Type: MCSA The nurse is reviewing the laboratory results for a patient with trauma. Based on this information, what care should the nurse plan for this patient?
1. fluids for distributive shock 2. nothing, because the results are normal 3. contact precautions 4. central venous catheter insertion Correct Answer: 2 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Distributive shock would involve a decrease in blood volume because of relative hypovolemia. Rationale 2: All the laboratory values are within normal limits. The WBC fall within the range of 5,000 to 10,000, neutrophils 55%–70%, monocytes 2%–8%, eosinophils 1%–4%, and lymphocytes 20%–40%. Rationale 3: The patient does not have an infection, so contact precautions are not necessary. Rationale 4: A central venous catheter is not required for this patient. Global Rationale: All the laboratory values are within normal limits. The WBC fall within the range of 5,000 to 10,000, neutrophils 55%–70%, monocytes 2%–8%, eosinophils 1%–4%, and lymphocytes 20%–40%. Distributive shock would involve a decrease in blood volume because of relative hypovolemia. The patient does not have an infection, so contact precautions are not necessary. A central venous catheter is not required for this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 5. Discuss diagnostic tests used in assessing patients experiencing trauma and shock. MNL Learning Outcome: 1.1.2. Differentiate the manifestations of fluid imbalances. Page Number: 251-252 Question 47 Type: FIB 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. Standard Text: Record your answer rounding to the nearest whole number. Correct Answer: 3 Rationale: 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 x 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 6.4.3. Examine the treatment options for cardiac perfusion disorders. Page Number: 253 Question 48 Type: MCMA A patient has received 145 mL of blood and complains of chills. For what should the nurse assess this patient? Standard Text: Select all that apply. 1. bradypnea 2. urticaria 3. fever 4. hypertension 5. lumbar pain Correct Answer: 2, 3, 5 Rationale 1: Reduced respiratory rate is not a manifestation of a hemolytic blood reaction. Rationale 2: Urticaria is a manifestation of a hemolytic blood reaction. Rationale 3: Fever is a manifestation of a hemolytic blood reaction. Rationale 4: Hypertension is not a manifestation of a hemolytic blood reaction. Rationale 5: Lumbar pain is a manifestation of a hemolytic blood reaction.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Manifestations of a hemolytic blood reaction include headache, dyspnea, urticaria, fever, hypotension, lumbar pain, abdominal pain, chills, and nausea and vomiting. Reduced respiratory rate and hypertension are not manifestations of a hemolytic blood reaction. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 6.4.3. Examine the treatment options for cardiac perfusion disorders. Page Number: 238 Question 49 Type: MCMA A patient in hypovolemic shock is receiving an intravenous colloid solution (plasma expander). Which assessment findings indicate to the nurse that the infusion rate should be reduced? Standard Text: 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 Correct Answer: 2,4,5 Rationale 1: A prothrombin time of 13.5 seconds is within normal range. Rationale 2: Jugular vein distention indicates circulatory overload and pulmonary edema. Rationale 3: Tenting of the skin would indicate dehydration and the need for more fluid replacement. Rationale 4: Increased central venous pressure indicates circulatory overload and pulmonary edema. Rationale 5: Crackles and wheezes indicate circulatory overload and pulmonary edema. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Jugular vein distention, increased central venous pressure, and crackles and wheezes indicate circulatory overload and pulmonary edema. The rate of infusion would be slowed and the physician notified. A prothrombin time of 13.5 seconds is within normal range. Tenting of the skin would indicate dehydration and the need for more fluid replacement. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.3. Examine the diagnosis and treatment of fluid imbalances. Page Number: 255 Question 50 Type: SEQ 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. Standard Text: Click and drag the options below to move them up or down. 1. assessment for obvious injuries 2. Champion Revised Trauma Scoring System 3. airway and breathing assessment 4. circulation assessment 5. level of consciousness and pupillary function Correct Answer: 3, 4, 5, 1, 2 Rationale 1: The fourth step is to assess for obvious injuries. Rationale 2: The last step is to use the Champion Revised Trauma Scoring System. Rationale 3: The first step is to assess the patient’s airway and breathing. Rationale 4: The second step is to assess the patient’s circulatory system. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: The third step is to assess the patient’s level of consciousness and pupillary function. Global Rationale: The airway and breathing assessment is completed first and the circulatory assessment second, following the principle of the ABCs. The airway must be patent to provide oxygen to the vital organs. The level of consciousness and pupillary function will indicate any head injury/spinal cord injury that must be immobilized before transport. The fourth step is to assess for obvious injuries. The Champion Revised Trauma Scoring System will indicate the patient’s chance of survival based on the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss causes, effects, and initial management of trauma. MNL Learning Outcome: 5.6.3. Explain the diagnosis and treatment of trauma of the chest, lungs, and supporting structures. Page Number: 235 Question 51 Type: SEQ 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? Standard Text: Click and drag the options below to move them up or down. 1: Stop the transfusion and notify the physician 2: Compare the blood slip with the unit of blood 3: Assess vital signs and associated manifestations 4: Save the blood bag and tubing for laboratory analysis 5: Collect urine and venous blood samples according to policy Correct Answer: 1, 3, 2, 4, 5 Rationale 1: The first step is to immediately stop the infusion and notify the physician. Rationale 2: The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. Rationale 3: The second step is to assess vital signs and assess for other manifestations. Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: The fifth step is to follow organizational policy for collecting urine and venous blood samples. Global Rationale: If manifestations of a blood transfusion reaction occur, the first step is to immediately stop the infusion and notify the physician. The second step is to assess vital signs and assess for other manifestations. The third step is to compare the blood slip with the unit of blood to ensure that an identification error was not made. 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. The fifth step is to follow organizational policy for collecting urine and venous blood samples. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.3. 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe collaborative interventions for patients experiencing trauma and shock, including medications, blood transfusion, and intravenous fluids. MNL Learning Outcome: 1.1.4. Utilize the nursing process in care of client. Page Number: 240 Question 52 Type: MCMA The nurse is concerned that a patient with traumatic chest injures is developing respiratory distress. What assessment findings led the nurse to come to this conclusion? Standard Text: 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 Correct Answer: 1, 2, 5 Rationale 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. Rationale 2: Absent breath sounds can indicate airway obstruction. Rationale 3: Changes in lower extremity pulses indicate an alteration in perfusion. Rationale 4: Changes in body temperature indicate an infectious process.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Oxygen saturation is a measurement of airway effectiveness. Oxygen flow should be adjusted to keep saturation level between 94% and 100%. Global Rationale: 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. Absent breath sounds can indicate airway obstruction. Oxygen saturation is a measurement of airway effectiveness. Oxygen flow should be adjusted to keep saturation level between 94% and 100%. Changes in lower extremity pulses indicate an alteration in perfusion. Changes in body temperature indicate an infectious process. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Integrity 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 5.6.4. Utilize the nursing process in care of client. Page Number: 241 Question 53 Type: MCMA An older patient with an infected stage IV pressure ulcer is lethargic. What additional findings should the nurse expect to assess in this stage of septic shock? Standard Text: Select all that apply. 1. warm, flushed skin 2. urine output 10 mL/hr 3. blood pressure 88/54 mmHg 4. heart rate 118 beats per minute 5. respiratory rate 28 per minute and shallow Correct Answer: 2, 3, 4, 5 Rationale 1: Warm, flushed skin is a manifestation of early (warm) septic shock. Rationale 2: Oliguria to anuria is a manifestation of late (cold) septic shock. A urine output of 10 mL/hr is oliguria. Rationale 3: Hypotension is a manifestation of late (cold) septic shock. A blood pressure of 88/54 mmHg indicates hypotension. Rationale 4: Tachycardia is a manifestation of late (cold) septic shock. A heart rate of 118 beats per minute is tachycardia. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Rapid shallow respirations are seen in late (cold) septic shock. A respiratory rate of 28 per minute and shallow indicates this stage of septic shock. Global Rationale: Manifestations of late (cold) septic shock include oliguria to anuria, hypotension, tachycardia, and rapid, shallow respirations. Warm, flushed skin is a manifestation of early (warm) septic shock. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Integrity 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 4.3.4. Utilize the nursing process in care of client. Page Number: 250 Question 54 Type: MCMA An adolescent is experiencing anaphylactic shock after being stung by a swarm of bees. Which medications should the nurse anticipate being provided to this patient? Standard Text: Select all that apply. 1. diuretics 2. antibiotics 3. epinephrine 4. beta2-agonist 5. antihistamine Correct Answer: 3, 4, 5 Rationale 1: Diuretics are used to increase urine output after fluid replacement has been initiated. Rationale 2: Antibiotics are used to suppress organisms in septic shock. Rationale 3: Epinephrine is used to treat anaphylactic shock. Rationale 4: Beta2-agonsts are used to treat anaphylactic shock. Rationale 5: Antihistamines are used to treat anaphylactic shock.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Epinephrine, antihistamines, and inhaled beta2-agonists are used to treat anaphylactic shock. Diuretics are used to increase urine output after fluid replacement has been initiated. Antibiotics are used to suppress organisms in septic shock. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.3. 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 252 Question 55 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 2, 3, 5 Rationale 1: For an alteration in perfusion, the nurse should auscultate lung sounds. Rationale 2: For an alteration in perfusion, the nurse should measure blood pressure. Rationale 3: For an alteration in perfusion, the nurse should measure current central venous pressure. Rationale 4: Reducing intravenous fluids could exacerbate the problem. Rationale 5: For an alteration in perfusion, the nurse should assess for jugular vein distention. Global Rationale: For an alteration in perfusion, the nurse should auscultate lung sounds, measure blood pressure, measure central venous pressure, and assess for jugular vein distention. Reducing intravenous fluids could exacerbate the problem. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.3. 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 10. Use the nursing process as a framework for providing individualized care to patients experiencing trauma and shock. MNL Learning Outcome: 6.4.4. Utilize the nursing process in care of client. Page Number: 255
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 12 Question 1 Type: MCSA The nurse is reviewing the white blood cell count differential for a patient and notes that the basophil count is elevated. 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. Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: Monocytes and macrophages activate the immune response against chronic infections such as tuberculosis, viral infections, and certain intracellular parasitic infections. Rationale 4: Dendritic cells activate T cells against cancer. Global Rationale: 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. 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. Monocytes and macrophages activate the immune response against chronic infections such as tuberculosis, viral infections, and certain intracellular parasitic infections. Dendritic cells activate T cells against cancer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care team LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 263 Question 2 Type: MCSA 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. Correct Answer: 1 Rationale 1: The spleen is not essential for life. If it is removed, the liver and bone marrow will take over its functions. Rationale 2: Having the spleen removed does not mean that the patient will need to avoid infections every day of his life. Rationale 3: Having the spleen removed does not mean that the patient will have edematous lymph glands throughout his body. Rationale 4: The thymus gland will not take over the spleen’s functions. Global Rationale: The spleen is not essential for life. If it is removed, the liver and bone marrow, not the thymus gland, will take over its functions. Having the spleen removed does not mean that the patient will need to avoid infections every day of his life or have edematous lymph glands throughout his body. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 265 Question 3 Type: MCSA A patient’s white blood cell count is 11,000/mm3. What does the nurse understand this value to represent? 1. the total number of circulating leukocytes 2. the total number of circulating neutrophils 3. the total number of circulating eosinophils 4. the total number of circulating basophils Correct Answer: 1 Rationale 1: In laboratory tests, the WBC count indicates the total number of circulating leukocytes. Rationale 2: The differential identifies the total number of circulating neutrophils. Rationale 3: The differential identifies the total number of circulating eosinophils. Rationale 4: The differential identifies the total number of circulating basophils. Global Rationale: In laboratory tests, the WBC count indicates the total number of circulating leukocytes. The differential identifies the total number of circulating neutrophils, eosinophils, and basophils. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 261 Question 4 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA A patient sustains fractures to the ribs, both femurs, and one humerus. When planning care for this patient’s immunologic status, what should the nurse include? 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. Correct Answer: 1 Rationale 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. Rationale 2: Food rich in iron should not be limited. Rationale 3: Performing passive range of motion to the unaffected extremities will not improve the patient’s immunologic status. Rationale 4: Staying on bed rest will not improve the patient’s immunologic status. Global Rationale: 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. Food rich in iron should not be limited. Performing passive range of motion to the unaffected extremities or keeping the patient on bed rest will not improve the patient’s immunologic status. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 265 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 5 Type: MCSA A patient is diagnosed with a positive tuberculosis skin test. The nurse understands that this response is due to what? 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 Correct Answer: 1 Rationale 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. Rationale 2: This is a characteristic of an antibody-mediated immune response. Rationale 3: This is a characteristic of an antibody-mediated immune response. Rationale 4: This is a characteristic of an antibody-mediated immune response. Global Rationale: 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. The other choices are characteristics of an antibody-mediated immune response. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 273
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 6 Type: MCSA A patient tells the nurse that he’s happy that his wife did not “catch” the same cold from which he has recently recovered. The nurse realizes that what most likely occurred in his wife? 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. Correct Answer: 1 Rationale 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 wife must have had a previous exposure to the same virus that caused the patient’s cold, and because of this “memory,” the body immediately responded by eliminating the cold virus. Rationale 2: Suppressor T cells stop the immune process and would not kill virus cells. Rationale 3: Phagocytosis of the virus by neutrophils is an antibody-mediated response. This scenario describes a cell-mediated immune response. Rationale 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. Global Rationale: 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 wife must have had a previous exposure to the same virus that caused the patient’s cold, and because of this “memory,” the body immediately responded by eliminating the cold virus. Suppressor T cells stop the immune process and would not kill virus cells. Phagocytosis of the virus by neutrophils is an antibody-mediated response. This scenario describes a cell-mediated immune response. 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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; apply health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 270 Question 7 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Immunoglobulin M is the first antibody produced in the primary immune response and is first produced during embryonic development. Rationale 3: Immunoglobulin E is the primary antibody in the allergic response. Rationale 4: Immunoglobulin D is the cell that is least understood and is present in small quantities in the blood. Global Rationale: 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. Immunoglobulin M is the first antibody produced in the primary immune response and is first produced during embryonic development. Immunoglobulin E is the primary antibody in the allergic response. Immunoglobulin D is the cell that is least understood and is present in small quantities in the blood. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 269 Question 8 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Immunoglobulin G is the only immunoglobulin to cross the placental barrier and provide immune protection to the neonate. Rationale 2: The baby does not need to be isolated. Rationale 3: The baby’s temperature will be checked routinely and evaluated for signs of infection. Rationale 4: This response would be inappropriate. Global Rationale: Immunoglobulin G is the only immunoglobulin to cross the placental barrier and provide immune protection to the neonate. The baby does not need to be isolated. The baby’s temperature will be checked routinely and evaluated for signs of infection. This response would be inappropriate. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 269 Question 9 Type: MCMA The nurse is concerned that a patient is exhibiting signs and symptoms of inflammation. What did the nurse assess to come to this conclusion? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: Leg edema is caused by accumulated fluid at the site. Rationale 2: Severe pain from tissue swelling is caused by chemical irritation of the nerve endings. Rationale 3: Severe erythema is a sign of inflammation. Rationale 4: Cool skin is not a sign of inflammation. Rationale 5: A change in pulse is not a sign of inflammation. Global Rationale: Signs of inflammation include edema, pain, and erythema. Cool skin and changes in pulses are not signs of inflammation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 278 Question 10 Type: MCSA 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 Correct Answer: 1 Rationale 1: A lack of protein prolongs inflammation and impairs the healing process. The nurse should encourage high-protein food choices in the diet. Rationale 2: If carbohydrates are limited, the body will use protein to meet caloric needs. This would impair healing. Rationale 3: Vitamin E is not identified as a vitamin to promote wound healing. Rationale 4: Restricting caloric intake could further compromise this patient and delay healing. Global Rationale: A lack of protein prolongs inflammation and impairs the healing process. The nurse should encourage high-protein food choices in the diet. If carbohydrates are limited, the body will use protein to meet caloric needs. This would impair healing. Vitamin E is not identified as a vitamin to promote wound healing. Restricting caloric intake could further compromise this patient and delay healing. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 279
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 11 Type: MCSA 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 Correct Answer: 1 Rationale 1: Systemic reactions associated with an inflammatory response include an increase in the size of lymph nodes, fever, loss of appetite, fatigue, and leukocytosis. Rationale 2: Erythema indicates a local reaction. Rationale 3: Edema indicates a local reaction. Rationale 4: Pain indicates a local reaction. Global Rationale: Systemic reactions associated with an inflammatory response include an increase in the size of lymph nodes, fever, loss of appetite, fatigue, and leukocytosis. Erythema, warmth, pain, edema, and functional impairment indicate a local reaction. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 278 Question 12 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient recovering from knee surgery has a surgical infection. What findings indicate that the patient is experiencing a systemic reaction? Standard Text: Select all that apply. 1. WBC 14,200 mm3 2. 10% bands 3. erythema 4. pain at the surgical site 5. respiratory rate of 16 Correct Answer: 1,2 Rationale 1: An elevated white blood cell count is an indication of a systemic reaction to the infection. Rationale 2: An elevated band count is an indication of a systemic reaction to the infection. Rationale 3: Erythema is a local reaction to an infection. Rationale 4: Pain is a local reaction to an infection. Rationale 5: A respiratory rate of 16 is a normal finding. Global Rationale: Signs of a systemic infection include an elevated white blood cell count and elevated band count. Erythema and pain are indications of a local reaction to an infection. A respiratory rate of 16 is a normal finding. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 278 Question 13 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is concerned that an older adult patient could be at risk for developing an infection. Which intervention led to this concern for the patient? 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 Correct Answer: 1 Rationale 1: Invasive procedures and altered immune defenses are the main factors contributing to hospitalacquired infection. Urinary catheterization is the number one cause. Rationale 2: The use of anti-embolism stockings is not associated with the onset of nosocomial infections. Rationale 3: Ambulation with a walker is not associated with nosocomial infections. Rationale 4: Medicating for pain is not associated with nosocomial infections. Global Rationale: Invasive procedures and altered immune defenses are the main factors contributing to hospitalacquired infection. Urinary catheterization is the number one cause. The use of anti-embolism stockings, ambulating with a walker, and medicating for pain are not associated with nosocomial infections. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 288 Question 14 Type: MCSA 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?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 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. Rationale 2: Prophylactic antibiotic therapy could lead to the growth of bacteria-resistant microorganisms. Rationale 3: The use of a mask is not needed to prevent the onset of infection in the patient. Rationale 4: The use of a gown and gloves is not needed to prevent the onset of infection in the patient. Global Rationale: 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. Prophylactic antibiotic therapy could lead to the growth of bacteria-resistant microorganisms. The use of a mask, gown, or gloves is not needed to prevent the onset of infection in the patient. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 293 Question 15 Type: MCSA A patient has been intubated to receive care in the intensive care unit. The nurse recognizes that the patient is at risk of developing which types of infection? 1. pneumonia LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. urinary tract infection 3. surgical wound infection 4. intravenous site infection Correct Answer: 1 Rationale 1: Hospital-acquired pneumonia accounts for 15% of hospital-acquired infections and is usually associated with ICU stays and mechanical ventilation. Rationale 2: There is not enough information to determine if the patient is at risk for developing a urinary tract infection. Rationale 3: There is not enough information to determine if the patient has a surgical wound. Rationale 4: Although intravenous site infections can occur, the risk for another type of infection is greater for this patient. Global Rationale: Hospital-acquired pneumonia accounts for 15% of hospital-acquired infections and is usually associated with ICU stays and mechanical ventilation. There is not enough information to determine if the patient is at risk for developing a urinary tract infection. There is not enough information to determine if the patient has a surgical wound. Although intravenous site infections can occur, the risk for another type of infection is greater for this patient. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 285 Question 16 Type: MCSA 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 1: Universal 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. Rationale 2: Transferring the patient to a semiprivate room would not reduce the spread of infection. Rationale 3: Limiting exposure to this patient could compromise the patient’s care. Rationale 4: Restricting visitors and planning activities to coincide with meal delivery t imes would compromise this patient’s care. Global Rationale: Universal 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. Transferring the patient to a semiprivate room would not reduce the spread of infection. Limiting exposure to this patient could compromise the patient’s care. Restricting visitors and planning activities to coincide with meal delivery times would also compromise this patient’s care. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 286 Question 17 Type: MCSA The nurse is instructing a patient on ways to prevent the onset of infection. What should the nurse include in these instructions? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 1: One way to reduce the spread of infection is to use disposable tissues for nasal secretions and wash the hands afterwards. Rationale 2: Reusing disposable razors could cause an infection. Rationale 3: Antibiotics should be taken as prescribed, not until symptoms subside. Rationale 4: Limiting interactions with people and crowds is one way to reduce the spread of infection. Global Rationale: One way to reduce the spread of infection is to use disposable tissues for nasal secretions and wash the hands afterwards. Reusing disposable razors could cause an infection. Antibiotics should be taken as prescribed, not until symptoms subside. Limiting interactions with people and crowds is one way to reduce the spread of infection. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 293 Question 18 Type: MCSA 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. to identify red man syndrome 2. to recognize the ototoxicity effect LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. to prevent a superinfection 4. to begin treatment for hives Correct Answer: 1 Rationale 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. Rationale 2: Vancomycin is not associated with ototoxicity. Rationale 3: Vancomycin is not associated with superinfection. Rationale 4: Vancomycin is not associated with hives. Global Rationale: 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. Vancomycin is not associated with ototoxicity, superinfection, or hives. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 290 Question 19 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. 30 minutes after the intravenous administration of the medication 4. during the infusion of the antibiotic Correct Answer: 1 Rationale 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. Rationale 2: The peak level would be 1–2 hours after the oral administration of a medication. Rationale 3: The peak level would occur 30 minutes after the intravenous administration of a medication. Rationale 4: Drawing the blood during the infusion of the antibiotic would not yield either a peak or a trough level. Global Rationale: 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. The peak level would be 1–2 hours after the oral administration of a medication and 30 minutes after the intravenous administration of a medication. Drawing the blood during the infusion of the antibiotic would not yield either a peak or a trough level. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 288 Question 20 Type: MCSA A patient diagnosed with active tuberculosis is being admitted to the hospital. For which type of isolation should the nurse prepare this patient? 1. airborne precautions 2. standard precautions
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. droplet precautions 4. contact precautions Correct Answer: 1 Rationale 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. Rationale 2: Standard precautions are infection control practices used for every patient. Rationale 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 largeparticle droplets generated during coughing, sneezing, talking, or procedures such as suctioning. Rationale 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. Global Rationale: 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 used by everyone entering the room. Standard precautions are infection control practices used for every patient. 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. 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. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 5.4.4. Utilize the nursing process in care of client. Page Number: 292 Question 21 Type: MCSA The nurse needs to obtain a sputum specimen for culture and sensitivity from a patient. When should the nurse obtain this specimen? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 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. Rationale 2: If the specimen were collected after the first dose of the antibiotic, there might not be sufficient microorganisms available for culture. Rationale 3: If the specimen were collected after the first dose of the antibiotic, there might not be sufficient microorganisms available for culture. Rationale 4: It would not be appropriate to obtain the first specimen as the first dose of antibiotics is being administered. Global Rationale: 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. If the specimen were collected during or after administration of the first dose of the antibiotic, there might not be sufficient microorganisms available for culture. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 5.3.4. Utilize the nursing process in care of client. Page Number: 293 Question 22 Type: MCMA A patient develops hyperthermia related to a diagnosis of pneumonia. Which interventions should the nurse perform to help with this problem? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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. Correct Answer: 1, 2, 3 Rationale 1: Reducing the temperature of the room is one way to promote body cooling without causing the patient to shiver. Rationale 2: Antipyretic medications lower the body temperature. Rationale 3: Rest will reduce metabolic demands on the body. Rationale 4: Ice packs could cause shivering and should be used with caution. Rationale 5: Restricting fluids could cause the body temperature to rise. The patient will need additional fluids. Global Rationale: Reducing the temperature of the room is one way to promote body cooling without causing the patient to shiver. Antipyretic medications lower the body temperature. Rest will reduce metabolic demands on the body. Ice packs could cause shivering and should be used with caution. Restricting fluids could cause the body temperature to rise. The patient will need additional fluids. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 294 Question 23 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse needs to change a patient’s abdominal wound dressing. Which techniques should the nurse use? 1. standard precautions 2. contact precautions 3. droplet precautions 4. airborne precautions Correct Answer: 1 Rationale 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. Rationale 2: The patient does not have a diagnosed wound infection, so contact precautions are not necessary. Rationale 3: The patient does not have a diagnosed disorder that would necessitate droplet precautions. Rationale 4: The patient does not have a diagnosed disorder that would necessitate airborne precautions. Global Rationale: 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. The patient does not have a diagnosed wound infection, so contact precautions are not necessary. The patient also does not have a diagnosed disorder that would necessitate droplet or airborne precautions. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 291 Question 24 Type: MCSA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 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. Rationale 2: Another step should be completed first. Rationale 3: Another step should be completed first. Rationale 4: Another step should be completed first. Global Rationale: 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. After the hands have been washed, the nurse can document, preparing medications, or discuss further care needs. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 293 Question 25 Type: MCHS When caring for a patient with an infection, the nurse provides a stethoscope that remains in the patient’s room. Place an “X” where the chain of infection is being interrupted.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Taking equipment into and out of the room of a patient with an infection provides an opportunity for bacteria to be transmitted from one person to another. The stethoscope acts as an indirect contact with the microorganisms. The stethoscope is not the microorganism, the reservoir, or portal of exit. The portal of entry would be a way for the microorganism to enter the host, and the host would be the patient. Global Rationale: Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 283 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 26 Type: MCHS A patient has had skin testing to assess cell-mediated immunity. Place an “X” in the area the nurse will monitor for the next 48 hours.
Correct Answer: Rationale: The skin testing for cell-mediated immunity is done via intradermal injection of an antigen such as tuberculin purified protein derivative. No other area on the body is used for intradermal injections. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 273 Question 27 Type: MCSA The nurse is reviewing a patient’s laboratory results. What conclusion should the nurse make after reviewing these results?
1. adequate nutritional status 2. risk for impaired immunity 3. antigen–antibody reaction 4. autoimmune disorder Correct Answer: 2 Rationale 1: The nutritional status is not adequate, as the protein levels are decreased. Rationale 2: The patient is at risk for impaired immunity as the total protein is low (normal 6–8 g/dL), the albumin is low (normal 3.2–4.5 g/dL), and globulin is low (normal 2.3–3.4 g/dL). Normal levels of protein are needed to maintain immunocompetence. Rationale 3: The antigen–antibody reaction is not related to low levels of protein in this situation. Rationale 4: The protein levels do not indicate that the patient has an autoimmune disorder. Global Rationale: The patient is at risk for impaired immunity as the total protein is low (normal 6–8 g/dL), the albumin is low (normal 3.2–4.5 g/dL), and globulin is low (normal 2.3–3.4 g/dL). Normal levels of proteins are needed to maintain immunocompetence. The nutritional status is not adequate, as the protein levels are decreased, LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
the antigen–antibody reaction is not related to low levels of protein in this situation, and the protein levels do not indicate an autoimmune disorder. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 273 Question 28 Type: MCSA The nurse is reviewing data for a patient with a wound. Which type of precaution would the nurse identify as needed by this patient?
1. contact 2. droplet 3. airborne 4. reverse Correct Answer: 1 Rationale 1: A patient with an infected open wound must be placed under contact precautions to avoid crosscontamination with other patients and staff. Rationale 2: There is nothing to indicate that the patient has a respiratory infection. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: There is nothing to indicate that the patient has a respiratory infection. Rationale 4: Reverse isolation is for the patient who is immunocompromised. Global Rationale: A patient with an infected open wound must be placed under contact precautions to avoid cross-contamination with other patients and staff. Droplet and airborne precautions are not necessary as this is not a respiratory infection. Reverse isolation is for the patient who is immunocompromised. Cognitive Level: Analyzing Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 292 Question 29 Type: MCSA A patient comes to the emergency department complaining of dyspnea. Based on an analysis of the data provided, what should the nurse suspect is occurring with this patient?
1. pancytopenia 2. chronic bacterial infections 3. a respiratory infection 4. a hypersensitivity response LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 4 Rationale 1: Pancytopenia would be indicated by very low levels of the laboratory values. Rationale 2: The patient with a chronic bacterial infection would have an increased WBC count. Rationale 3: The patient with a respiratory infection would have an increased WBC count. Rationale 4: The eosinophils (normal 1–4%) and basophils (normal 0.5%–1%) respond in hypersensitivity responses. The lab values and dyspnea suggest a hypersensitivity response. Global Rationale: The eosinophils (normal 1%–4%) and basophils (normal 0.5%–1%) respond in hypersensitivity responses. The lab values and dyspnea suggest a hypersensitivity response. Pancytopenia would be indicated by very low levels of the laboratory values. A respiratory or chronic bacterial infection would show increases in the WBC (normal 4,000–10,000 per mm3), neutrophils (normal 55%–70%), monocytes (normal 2%– 8%), and lymphocytes (normal 20%–40%). Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 262-263 Question 30 Type: MCMA A patient is receiving an aminoglycoside. Which findings should the nurse immediately report? Standard Text: Select all that apply. 1. history of allergy to penicillins 2. weight gain of 5 kg in 2 days 3. symptoms of vertigo 4. fluid intake below 2,000 mL/day 5. new order for IV furosemide (Lasix) LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2, 3, 5 Rationale 1: A history of allergy to penicillin would apply to cephalosporins. Rationale 2: Aminoglycosides are nephrotoxic. A sudden weight gain indicates possible kidney damage and should be immediately reported. Rationale 3: The nurse should report the patient’s complaints of vertigo because aminoglycosides are ototoxic. Rationale 4: A patient on fluoroquinolones or sulfonamides must maintain a fluid intake of 2,000 to 3,000 mL/day. Rationale 5: Furosemide is ototoxic and should not be administered with other ototoxic medications such as aminoglycosides. Global Rationale: Aminoglycosides are nephrotoxic. A sudden weight gain indicates possible kidney damage and should be immediately reported. Aminoglycosides are also ototoxic, especially combined with other drugs that can cause ototoxicity such as furosemide and ethacrynic acid. A history of allergy to penicillin would apply to cephalosporins. A patient on fluoroquinolones or sulfonamides must maintain a fluid intake of 2,000 to 3,000 mL/day. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 290 Question 31 Type: FIB A patient is prescribed to receive linezolid (Zyvox) 600 mg intravenously twice a day. The nurse receives the medication 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 to deliver? Standard Text: Record your answer rounding to the nearest whole number. Correct Answer: 38
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale: 300 mL × 15 gtt/mL / 120 min 4500 / 120 = 37.5 37.5 rounds out to 38 gtt/min Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 290 Question 32 Type: MCMA The nurse is reviewing the antibody-mediated immune response with a patient experiencing a first exposure to an antigen. What events should the nurse explain that occur in this immune response? Standard Text: 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. Correct Answer: 2, 3, 5 Rationale 1: The antigen–antibody reaction includes a binding of the antigen (Fab). Rationale 2: The primary response begins with the initial encounter with an antigen. Rationale 3: Memory B cells and plasma cells are cloned after the initial encounter with the antigen.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: T cells take part in cellular immunity. Rationale 5: During initial exposure to an antigen, the antigen is bound to the antibody, which stimulates cell growth, division, and differentiation. Global Rationale: The primary response begins with the initial encounter with an antigen. During initial exposure to an antigen, the antigen is bound to the antibody, which stimulates cell growth, division, and differentiation. Memory B cells and plasma cells are cloned after the initial encounter with the antigen. This allows for a faster reaction the second time the body encounters the antigen. The antigen–antibody reaction includes a binding of the antigen (FAB). T cells take part in cellular immunity. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 268 Question 33 Type: MCMA The nurse suspects that a patient is experiencing a local inflammatory response. What findings would support this conclusion? Standard Text: 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 Correct Answer: 2, 4, 5 Rationale 1: The temperature may be increased or decreased in response to a systemic infection.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: One sign of a local inflammatory response is warmth. Rationale 3: The platelet response would be related to a systemic event. Rationale 4: One sign of a local inflammatory response is edema. Rationale 5: One sign of a local inflammatory response is functional impairment. Global Rationale: The signs of a local inflammatory response are warmth, edema, and functional impairment. The temperature may be increased or decreased in response to a systemic infection. The platelet response would be related to a systemic event. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 278 Question 34 Type: MCMA A patient has been prescribed cefuroxime (Ceftin). What should the nurse teach the patient about this medication? Standard Text: 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. Correct Answer: 1, 4, 5 Rationale 1: Cefuroxime (Ceftin) is a cephalosporin and must be taken on an empty stomach. Rationale 2: This cephalosporin is not identified as causing alcohol intolerance. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Hearing loss applies to the aminoglycosides. Rationale 4: Yogurt helps prevent intestinal superinfection. Rationale 5: The entire prescription must be completed in order to be effective. Global Rationale: Cefuroxime (Ceftin) is a cephalosporin and must be taken on an empty stomach. Yogurt helps prevent intestinal superinfection, and the entire prescription must be completed in order to be effective. Hearing loss applies to the aminoglycosides. This cephalosporin is not identified as causing alcohol intolerance. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 289 Question 35 Type: MCSA A patient who has never experienced a reaction to a bee sting comes into the emergency department with intense edema and redness at the site of the sting. The nurse realizes that this patient is demonstrating which type of immune response? 1. mobilization of lymphocytic memory T cells 2. activation of granulocytes 3. creation of neutrophils 4. circulation of eosinophils Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Granulocytes protect against harmful microorganisms during a period of acute inflammation. Rationale 3: Neutrophils are responsible for phagocytosis and chemotaxis. Rationale 4: Eosinophils are responsible for phagocytosis and provide protection against parasites. Global Rationale: 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. Granulocytes protect against harmful microorganisms during a period of acute inflammation. Neutrophils are responsible for phagocytosis and chemotaxis. Eosinophils are also responsible for phagocytosis and provide protection against parasites. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 264 Question 36 Type: MCSA A patient recovering from a splenectomy asks the nurse, “What’s going to happen to me now that my spleen is gone?” What is an appropriate nursing response? 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.” Correct Answer: 3 Rationale 1: The patient will still be able to recover from colds and the flu. Rationale 2: The stomach does not assume the spleen’s functions.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 4: This response does not necessarily answer the patient’s question adequately. Global Rationale: 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. The patient will still be able to recover from colds and the flu. The stomach does not assume the spleen’s functions. Telling the patient the spleen is not necessary, although not inaccurate, does not adequately address the question. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: II.B.4. Function competently within own scope of practice as a member of the health care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 265 Question 37 Type: MCMA The nurse is caring for a patient with a localized inflammatory response. Which stages should the nurse expect the patient to experience with this response? Standard Text: Select all that apply. 1. basilar 2. cellular 3. vascular 4. tissue repair 5. keratosis Correct Answer: 2, 3 Rationale 1: Basilar does not describe a phase of the inflammatory response. Rationale 2: The inflammatory response has two stages, one of which is the cellular response. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: The inflammatory response has two stages, one of which is the vascular response, characterized by vasodilation and increased permeability of blood vessels. Rationale 4: Phagocytosis sets the stage for healing and tissue repair. Rationale 5: Keratosis is not a phase of the inflammatory response. Global Rationale: The inflammatory response has two stages: a vascular response characterized by vasodilation and increased permeability of blood vessels, and a cellular response. Phagocytosis sets the stage for healing or tissue repair. Basilar does not describe a phase of the inflammatory response. Keratosis is not a phase of the inflammatory response. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Explain the components and functions of the immune system and the immune response. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 265 Question 38 Type: MCSA A patient with an inflammatory response is prescribed a nonsteroidal anti-inflammatory drug (NSAID). The nurse understands the patient was prescribed this medication for which reason? 1. to increase the production of histamine 2. to increase the flow of serosanguineous drainage 3. to reduce the production of serotonin 4. to reduce prostaglandin synthesis Correct Answer: 4 Rationale 1: Histamine production is increased by the use of an NSAID. Rationale 2: The flow of serosanguineous drainage is not associated with the actions of nonsteroidal antiinflammatory medications.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Serotonin is contained in the granules of basophils and is not impacted by NSAIDs. Rationale 4: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as well as glucocorticoids, inhibit prostaglandin synthesis and thereby reduce fever, pain, and inflammation. Global Rationale: Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs), as well as glucocorticoids, inhibit prostaglandin synthesis and thereby reduce fever, pain, and inflammation. Histamine production is increased by the use of an NSAID. The flow of serosanguineous drainage is not associated with the actions of nonsteroidal anti-inflammatory medications. Serotonin is contained in the granules of basophils and is not impacted by NSAIDs. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 266 Question 39 Type: MCSA 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 Correct Answer: 3 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 4: The information is insufficient to determine the need for a specific type of isolation. Global Rationale: 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. The information is insufficient to determine the need for a specific type of isolation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 271 Question 40 Type: MCSA One school district is not requiring vaccinations for children who are starting school. The nurse realizes that this action could have which consequence? 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 Correct Answer: 4 Rationale 1: Healthier children are not the result of reduced immunization. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The lack of immunization will not impact the number of colds and flu outbreaks in a school system. Rationale 3: High rates of illness may increase school costs. Rationale 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. Global Rationale: 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. Healthier children are not the result of reduced immunization. The lack of immunization will not impact the number of colds and flu outbreaks in a school system. High rates of illness may increase school costs. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 271 Question 41 Type: MCSA A patient is having skin testing done to assess for allergies. What would 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 Correct Answer: 4 Rationale 1: Itching is not a sign of exposure to an antigen. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: An induration of at least 10 mm in diameter is a positive reaction that indicates previous exposure and sensitization to the antigen. Rationale 3: Induration and erythema typically peak at 24 to 48 hours. Rationale 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. Global Rationale: 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. Itching is not a sign of exposure to an antigen. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 273 Question 42 Type: MCSA 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. Correct Answer: 4 Rationale 1: A blood culture is used to diagnose the presence of an infection.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: A single dose of this vaccine confers lifetime immunity, although repeating immunization every 5 years may be considered for high-risk patients. Rationale 3: The flu vaccine and the pneumococcal vaccine are not the same. Rationale 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. Global Rationale: 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. A blood culture is used to diagnose the presence of an infection. The flu vaccine and the pneumococcal vaccine are not the same. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 273 Question 43 Type: MCSA 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. Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: There is inadequate information to determine if the patient has an allergy to the vaccine. Rationale 3: There is not enough information to determine if the patient has been scratching at the site. Rationale 4: It is unlikely the patient has developed the disease that the inoculation was intended to prevent. Global Rationale: 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. There is inadequate information to determine if the patient has an allergy to the vaccine or has been scratching. It is unlikely the patient has developed the disease that the inoculation was intended to prevent. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 274 Question 44 Type: MCMA A patient asks the nurse how long it will be before a leg wound heals. What phases of wound healing should the nurse explain to this patient? Standard Text: Select all that apply. 1. inflammation 2. deconstruction 3. reconstruction 4. resolution 5. dissolution Correct Answer: 1, 3, 4 Rationale 1: Inflammation is the first phase of the healing process.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Deconstruction is not a phase of the healing process. Rationale 3: The second phase of the healing process, known as reconstruction, may overlap the inflammatory phase. Rationale 4: The ideal result of the healing process is resolution, which is the restoration of the original structure and function of the damaged tissue. Rationale 5: Dissolution is not a phase of the healing process. Global Rationale: Inflammation is the first phase of the healing process. The second phase, known as reconstruction, may overlap the inflammatory phase. The ideal result of the healing process is resolution, which is the restoration of the original structure and function of the damaged tissue. Deconstruction and dissolution are not phases of the healing process. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.1. Explain the pathophysiology of hypersensitivity reactions. Page Number: 267 Question 45 Type: MCMA The nurse is assessing a patient’s arm for inflammation. Which are signs that a localized inflammatory process is occurring? Standard Text: Select all that apply. 1. purulent drainage 2. pain 3. hyperemia 4. erythema 5. induration LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2, 3, 4 Rationale 1: Purulent drainage typically accompanies an infection. Rationale 2: Pain from tissue swelling and chemical irritation of nerve endings is a sign of a localized inflammatory process. Rationale 3: Increased blood flow to the injured area, causing hyperemia, is a sign of a localized inflammatory process. Rationale 4: Erythema is a sign of a local inflammatory process. Rationale 5: Induration is not a sign of a local inflammatory process. Global Rationale: The signs of inflammation include erythema, local heat caused by the increased blood flow to the injured area (hyperemia), and pain from tissue swelling and chemical irritation of nerve endings. Purulent drainage typically accompanies an infection. Induration is not a sign of a local inflammatory process. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 278 Question 46 Type: MCSA 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 Correct Answer: 2 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Water provides hydration. Hydration is needed for the body but is not the key nutrient for the promotion of healing. Rationale 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. Rationale 3: Carbohydrates are needed for energy. Rationale 4: Fats are a source of warmth, and the excess is stored for later use. Global Rationale: 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. Water provides hydration, which is needed by the body but is not the key nutrient for the promotion of healing. Carbohydrates are needed for energy. Fats are a source of warmth, and the excess is stored for later use. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 280 Question 47 Type: MCSA A patient wants to know why he developed an infection after being cut on the leg with a piece of wood, but his 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.” Correct Answer: 3 Rationale 1: There is no evidence the wood was or was not contaminated.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: An autoimmune disorder would not cause an infection in this situation. Rationale 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. Rationale 4: There is no evidence to indicate that the friend will develop an infection. Global Rationale: 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. There is no evidence to indicate that the friend will develop an infection or that the wood was or was not contaminated. An autoimmune disorder would not cause an infection in this situation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 283 Question 48 Type: MCSA A patient is resisting the use of incentive spirometry postoperatively. What should the nurse explain about this device? 1. “It will help prevent the development of pneumonia.” 2. “It gives you something to do while recovering.” 3. “It will prevent you from getting a cold.” 4. “The doctor ordered it.” Correct Answer: 1 Rationale 1: Hospital-acquired pneumonia is a common hospital-acquired infection with the highest morbidity and mortality rate. Explaining the correct rationale for the use of the device will increase the chances of compliance in a patient. Rationale 2: Incentive spirometry is not intended as a diversionary tool. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Incentive spirometry does not reduce the risk of getting a cold. Rationale 4: Although the physician may have ordered the treatment, this response does not address the patient’s need for information. Global Rationale: Hospital-acquired pneumonia is a common hospital-acquired infection with the highest morbidity and mortality rate. Explaining the correct rationale for the use of the device will increases the chances of compliance in a patient. Incentive spirometry is not intended as a diversionary tool and does not reduce the risk of getting a cold. Although the physician may have ordered the treatment, this response does not address the patient’s need for information. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 285 Question 49 Type: MCSA 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 Correct Answer: 4 Rationale 1: Penicillin is not identified as a medication to treat vancomycin-resistant S. aureus. Rationale 2: Gentamycin is not identified as a medication to treat vancomycin-resistant S. aureus. Rationale 3: Tetracycline is not identified as a medication to treat vancomycin-resistant S. aureus.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Global Rationale: 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. Penicillin, gentamycin, and tetracycline are not identified as medications to treat vancomycin-resistant Staphylococcus aureus. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 4. Identify factors responsible for and the implications of healthcare-associated infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 290 Question 50 Type: MCSA 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. Correct Answer: 3 Rationale 1: The medication should not be taken on a full stomach. Rationale 2: The medication should not be taken with a glass of milk. Rationale 3: The most commonly prescribed macrolide is erythromycin (E-mycin), which should be taken on an empty stomach and without acidic juice. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The medication should not be taken with juice. Global Rationale: The most commonly prescribed macrolide is erythromycin (E-mycin), which should be taken on an empty stomach and without acidic juice. A full glass of water is suggested instead of milk or another beverage. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 290 Question 51 Type: MCSA 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 Correct Answer: 4 Rationale 1: Head covering and gown are not necessary when caring for this patient. Rationale 2: Shoe covering and gown are not necessary when caring for this patient. Rationale 3: Gloves alone are not adequate protection against droplet secretions. Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Head and shoe covers and gowns would not protect the areas vulnerable to droplets. Gloves alone are not adequate protection against droplet secretions. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 292 Question 52 Type: MCMA 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? Standard Text: 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 Correct Answer: 3, 4, 5 Rationale 1: A history of ovarian cysts does not increase the risk of contracting hepatitis B. Rationale 2: Down syndrome does not increase the risk of contracting hepatitis B. Rationale 3: Hepatitis B vaccine is recommended for people with end-stage renal disease. Rationale 4: Hepatitis B vaccine is recommended for people newly diagnosed with diabetes mellitus who are under age 60. Rationale 5: Hepatitis B vaccine is recommended for people with chronic liver disease. Global Rationale: Hepatitis B (HB) vaccine is recommended for people newly diagnosed with diabetes mellitus who are under age 60 years and for those in high-risk populations such as patients with end-stage renal disease or chronic liver disease. The vaccine is not recommended for those with ovarian cysts or Down syndrome. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: 2. Compare antibody-mediated and cell-mediated immune responses. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 273 Question 53 Type: MCMA A patient being treated for a stage 3 pressure ulcer is demonstrating delayed healing. What information in the patient’s medical record and history would explain this delay? Standard Text: 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 was diagnosed with peripheral vascular disease 5 years ago. 4. The patient was prescribed steroids for treatment of chronic lung condition. 5. The patient takes acetaminophen 650 mg twice a day for arthritis pain. Correct Answer: 2, 3, 4 Rationale 1: A history of total knee replacement would not delay healing in this patient. Rationale 2: Chronic diseases may impair healing. High blood glucose levels impair chemotactic and phagocytic function. Rationale 3: 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. Rationale 4: Drug therapy with corticosteroids may suppress the immune and inflammatory responses and delay healing. Rationale 5: Acetaminophen is not identified as a medication that adversely affects healing. Global Rationale: Chronic diseases may impair healing. High blood glucose levels impair chemotactic and phagocytic function. 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. Drug therapy with corticosteroids may suppress the immune and inflammatory responses and delay healing. A history of total knee replacement would not delay healing in this patient. Acetaminophen is not identified as a medication that adversely affects healing. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Evaluation Learning Outcome: 3. Describe the pathophysiology of wound healing, inflammation, and infection. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 278 Question 54 Type: MCMA 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? Standard Text: 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. Correct Answer: 1, 3 Rationale 1: Elevation promotes venous return and reduces swelling. Rationale 2: Fluid intake may or may not impact healing of the inflammation. Rationale 3: One action to reduce the pain of an inflamed area is to take analgesics as prescribed. Rationale 4: Strenuous activity or exercising an inflamed body part may increase discomfort and tissue damage. Rest should be encouraged. Rationale 5: Inflamed tissue should be cleansed gently with water, normal saline, or nontoxic wound cleansers. Soap can cause further drying and tissue damage. Global Rationale: Elevation promotes venous return and reduces swelling. One action to reduce the pain of an inflamed area is to take analgesics as prescribed. Fluid intake may or may not impact healing of the inflammation. Strenuous activity or exercising an inflamed body part may increase discomfort and tissue damage. Rest should be encouraged. Inflamed tissue should be cleansed gently with water, normal saline, or nontoxic wound cleansers. Soap can cause further drying and tissue damage. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 5. Discuss the purposes, nursing implications, and health education for medications and treatments used to treat inflammations and infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 281 Question 55 Type: MCMA The daughter of an older patient asks why the patient is experiencing frequent episodes of pneumonia. What factors should the nurse discuss when responding? Standard Text: 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 Correct Answer: 2, 3, 5 Rationale 1: Diminished thirst reflex does not directly contribute to the development of pneumonia in the older patient. Rationale 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. Rationale 3: The older adult may produce less sputum due to decreased immune function. Rationale 4: Reduced bladder contractility in the older patient would contribute to the development of urinary tract infections. Rationale 5: Decreased mucociliary clearance reduces the clearance of respiratory secretions and increases the risk for pneumonia. Global Rationale: 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. The older adult may produce less sputum due to decreased immune function. Decreased mucociliary clearance reduces the clearance of respiratory secretions and increases the risk for pneumonia. Diminished thirst reflex does not directly contribute to the development of pneumonia in the older patient. Reduced bladder contractility in the older patient would contribute to the development of urinary tract infections. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 287 Question 56 Type: MCMA A patient is prescribed metronidazole (Flagyl) for treatment of C. difficile. What should the nurse include when teaching the patient about this medication? Standard Text: 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. Correct Answer: 1, 2, 5 Rationale 1: Alcohol should not be ingested while taking this medication. A severe reaction can occur. Rationale 2: Fluid intake should be 2-1/2 to 3 quarts each day. Rationale 3: This medication may turn urine reddish brown, which is expected and not harmful. Rationale 4: The healthcare provider should be contacted about any changes in mentation or coordination. Rationale 5: The healthcare provider should be contacted if urination becomes painful. Global Rationale: Alcohol should not be ingested while taking this medication. A severe reaction can occur. Fluid intake should be 2-1/2 to 3 quarts each day. The healthcare provider should be contacted if urination becomes painful. This medication may turn urine reddish brown, which is expected and not harmful. The healthcare provider should be contacted about any changes in mentation or coordination. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1.Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 6. Explain the nursing care necessary to prevent and/or monitor the status of infections. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 291
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 13 Question 1 Type: MCSA A patient is admitted to receive a kidney transplant from a live sibling. The nurse realizes that 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. Correct Answer: 1 Rationale 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. Rationale 2: If the human leukocyte antigen type were different, the surgery would not be successful. Rationale 3: There is not enough information to determine if the patient has an overactive immune system. Rationale 4: There is not enough information to determine if the donor has an overactive immune system. Global Rationale: 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. If the human leukocyte antigen type were different, the surgery would not be successful. There is not enough information to determine if either patient or donor has an overactive immune system. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Review the normal immune system function, including self-recognition. MNL Learning Outcome: 2.3.1. Examine the types, histocompatibility, and pathophysiology of tissue transplantation and rejection. Page Number: 298 Question 2 Type: MCSA A patient in isolation for an incompetent immune system asks the nurse what “disease” he has that requires 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.” Correct Answer: 1 Rationale 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. Rationale 2: The nurse does not need to ask the physician about the patient’s isolation. Rationale 3: The patient does not have a specific disease that might spread. Rationale 4: The patient may be on medication; however, it is not to treat a specific disease. Global Rationale: 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. The nurse does not need to ask the physician about the patient’s isolation. The patient does not have a specific disease that might spread. The patient may be on medication; however, it is not to treat a specific disease. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Review the normal immune system function, including self-recognition. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 313 Question 3 Type: MCSA A patient tells the nurse that she used to get the “common cold” at least three times a year but now can’t remember the last time she had one. 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 Correct Answer: 1 Rationale 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. Rationale 2: Another type of lymphocyte is responsible for this phenomenon. Rationale 3: T cells do not secrete antibodies. Rationale 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. Global Rationale: 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. T cells do not secrete antibodies. 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 “non self,” cytotoxic T cells also attack malignant cells and are responsible for the rejection of transplanted organs and grafted tissues. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Review the normal immune system function, including self-recognition. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 298 Question 4 Type: MCSA An older patient tells the nurse that he develops pneumonia easily; however, his wife 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 wife must be doing something that you’re not doing.” 3. “Maybe your wife just doesn’t tell you when she’s sick.” 4. “It’s just a matter of time. Your wife will have the same illnesses you do.” Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not say that the patient’s wife is doing something that the patient is not doing. Rationale 3: The nurse should not say that the wife might not be telling the patient when she is ill. Rationale 4: The nurse has no way of knowing if the wife’s immune system is going to change or when. Global Rationale: 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. The nurse should not say that the patient’s wife is doing something that the LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
patient is not doing, or that the wife might not be telling the patient when she is ill. The nurse has no way of knowing if the wife’s immune system is going to change or when. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 1. Review the normal immune system function, including self-recognition. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 298 Question 5 Type: MCSA A patient comes into the emergency department with itching, swelling, and slight shortness of breath after being stung by a bee. The nurse realizes this patient is experiencing which type of hypersensitivity reaction? 1. type I IgE-mediated hypersensitivity 2. type II cytotoxic hypersensitivity 3. type III immune complex-mediated hypersensitivity 4. type IV delayed hypersensitivity Correct Answer: 1 Rationale 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. Rationale 2: A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. Rationale 3: Type III hypersensitivity reactions result from the formation of IgG or IgM antibody–antigen immune complexes in the circulation, leading to tissue damage. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Type IV delayed hypersensitivity reactions result from an exaggerated interaction between an antigen and normal cell-mediated mechanisms. Global Rationale: 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 that results in widespread antibody–antigen reaction and response to these chemical mediators, a systemic response such as anaphylaxis, urticaria, or angioedema occurs. A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. Type III hypersensitivity reactions result from the formation of IgG or IgM antibody–antigen immune complexes in the circulation, leading to tissue damage. Type IV delayed hypersensitivity reactions result from an exaggerated interaction between an antigen and normal cell-mediated mechanisms. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 299 Question 6 Type: MCSA A patient is diagnosed with a type IV delayed hypersensitivity reaction. What is an example of this type of reaction? 1. latex allergy 2. reaction to a wasp sting 3. serum sickness 4. autoimmune hemolytic anemia Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: A reaction to a wasp sting is an example of a type I reaction. Rationale 3: Serum sickness is an example of a type III reaction. Rationale 4: Autoimmune hemolytic anemia is an example of a type II reaction. Global Rationale: Contact dermatitis is a classic example of a type IV reaction. In the healthcare setting, an allergic response to latex can produce contact dermatitis. A reaction to a wasp sting is an example of a type I reaction. Serum sickness is an example of a type III reaction. Autoimmune hemolytic anemia is an example of a type II reaction. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 302 Question 7 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: A blood transfusion will not stop the reaction. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Oxygen will not stop the reaction. Rationale 4: Fluids will not stop the reaction. Global Rationale: 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. A blood transfusion, oxygen, or fluids will not stop the reaction. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 301 Question 8 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The patient is not experiencing an exacerbation of a disease process. Rationale 3: The patient is not experiencing acute influenza.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The patient is not experiencing subacute rheumatoid arthritis. Global Rationale: 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. The patient is not experiencing an exacerbation of a disease process, acute influenza, or subacute rheumatoid arthritis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 301 Question 9 Type: MCSA A patient who has received a bone marrow transplant develops a maculopapular rash on the palms of both hands and the soles of the feet. The patient complains of severe abdominal pain with 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 Correct Answer: 1 Rationale 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. Rationale 2: Chronic tissue rejection occurs from 4 months to years after the transplant of new tissue. Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
process, with fever, redness, swelling, elevated BUN, creatinine, lower enzymes, and elevated bilirubin and cardiac enzymes. Rationale 4: Hyperacute tissue rejection leads to rapid deterioration of organ function. Global Rationale: 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. Chronic tissue rejection occurs from 4 months to years after the transplant of new tissue. 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. Hyperacute tissue rejection leads to rapid deterioration of organ function. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the pathophysiology of autoimmune disorders and tissue transplant rejection. MNL Learning Outcome: 2.3.2. Differentiate the manifestations of tissue transplantation and rejection. Page Number: 309 Question 10 Type: MCSA A patient is diagnosed with valvular heart disease after experiencing rheumatic heart fever. The nurse understands this disorder is caused by what action? 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 Correct Answer: 1 Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
molecular mimicry. Heart damage in rheumatic fever is an example of the development of antibodies against normal tissue. Rationale 2: This is not the release of hidden antigens into the circulation. Rationale 3: This is not biologic changes that cause self-antigens to produce autoantibodies. Rationale 4: This is not an autoimmune response due to slow-growing mycobacteria. Global Rationale: 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. The other choices are explanations for the development of autoimmune disorders, but they do not describe the physiology of heart damage after rheumatic heart fever. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the pathophysiology of autoimmune disorders and tissue transplant rejection. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 306 Question 11 Type: MCSA A patient tells the nurse that she hopes she does not develop rheumatoid arthritis because her mother suffers so much pain with 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.” Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Stress is not the only cause of the disorder. Rationale 3: There is no information linking estrogen to the development of an autoimmune disorder. Rationale 4: Limiting physical activity will not prevent the onset of the disorder. Global Rationale: 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 the disorders. There is no information linking estrogen to the development of an autoimmune disorder. Stress is not the only cause of the disorder. Limiting physical activity will not prevent the onset of the disorder. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 3. Explain the pathophysiology of autoimmune disorders and tissue transplant rejection. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 307 Question 12 Type: MCSA A patient had skin taken from the upper thigh and placed over a burn area on the shoulder. The nurse expects which likely outcome for this patient? 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. Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Evidence of immediate cyanosis describes hyperacute tissue rejection. Rationale 3: Acute tissue rejection occurs within 3 to 4 months and is not typically seen with a skin graft. Rationale 4: Chronic tissue rejection occurs from 4 months to years after the transplant and is not typically seen with a skin graft. Global Rationale: 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. Evidence of immediate cyanosis describes hyperacute tissue rejection. Acute tissue rejection occurs within 3 to 4 months and is not typically seen with a skin graft. Chronic tissue rejection occurs from 4 months to years after the transplant and is not typically seen with a skin graft. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 3. Explain the pathophysiology of autoimmune disorders and tissue transplant rejection. MNL Learning Outcome: 2.3.2. Differentiate the manifestations of tissue transplantation and rejection. Page Number: 308 Question 13 Type: MCSA A patient is prescribed an immunosuppressive agent. Which statement indicates the patient needs additional instruction from the nurse about this drug? 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.” Correct Answer: 1 Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Rationale 2: The physician should be notified about any bruising. Rationale 3: Fluids should be increased to maintain good hydration and urinary output. Rationale 4: Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents. Global Rationale: 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. Fluids should be increased to maintain good hydration and urinary output. Ibuprofen is acceptable for immunosuppressive medications, but should not be taken with cytotoxic agents. The physician should be notified about any bruising. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Discuss the characteristics of immunodeficiencies. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 312 Question 14 Type: MCSA A patient who is immunosuppressed asks the nurse why he is experiencing so many illnesses. 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.”
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: The patient’s body does not take longer to develop an immune response. Rationale 3: The patient’s body does not think everything is foreign matter. Rationale 4: Severe stress is not causing the illnesses. Global Rationale: 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. The patient’s body does not take longer to develop an immune response or think everything is foreign matter. Severe stress is not causing the illnesses. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss the characteristics of immunodeficiencies. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 315 Question 15 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. elevated hematocrit level Correct Answer: 1 Rationale 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. Rationale 2: The normal range of the eosinophil count is 1%–4%. Rationale 3: The Coombs indirect test checks the recipient’s and donor’s blood for antibodies before a blood transfusion. Rationale 4: There is not enough information about the elevated hematocrit level. Global Rationale: A patch test assesses a one-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. The Coombs’ indirect test checks the recipient’s and donor’s blood for antibodies before a blood transfusion. The normal range of the eosinophil count is 1 %–4%. There is not enough information about the elevated hematocrit level. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 304 Question 16 Type: MCSA 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 cells count and differential 3. blood type and crossmatch
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. immune complex assay Correct Answer: 1 Rationale 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. Rationale 2: White blood cell count and differential is not used instead of skin testing if a severe allergic response is suspected. Rationale 3: Blood type and crossmatch is not used instead of skin testing if a severe allergic response is suspected. Rationale 4: Immune complex assay is not used instead of skin testing if a severe allergic response is suspected. Global Rationale: Radioallergosorbent test 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. White blood cell count and differential, blood type and crossmatch, and immune complex assay tests are not used instead of skin testing if a severe allergic response is suspected. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 303 Question 17 Type: MCSA 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
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. ulceration Correct Answer: 1 Rationale 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. Rationale 2: A localized, itchy wheal would be a positive response for a prick test. Rationale 3: Papules would be a positive response for a patch test. Rationale 4: An ulceration would be a positive response for a patch test. Global Rationale: 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. A localized itchy wheal would be a positive response for a prick test. Papules and ulceration would be a positive response for a patch test. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 304 Question 18 Type: MCSA A patient is following an elimination diet to help identify food allergies. After 1 week, 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 Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: If symptoms improve after an elimination diet, foods are reintroduced one at a time until symptoms recur, indicating allergy to that food. Rationale 2: The patient should not resume the pre-elimination diet. Rationale 3: The patient should not take an antihistamine prior to eating a food that has been identified as causing an allergy. Rationale 4: The patient should not consume foods known to cause an allergic response. Global Rationale: If symptoms improve after an elimination diet, foods are reintroduced one at a time until symptoms recur, indicating allergy to that food. The patient should not resume the pre-elimination diet, take an antihistamine prior to eating a food identified as causing an allergy, or consume foods known to cause an allergic response. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 304 Question 19 Type: MCSA A patient is experiencing symptoms of exposure to environmental ragweed. The nurse should instruct the patient on the use of which medication? 1. antihistamines 2. antibiotics 3. antiviral medications 4. antifungal medications Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: The patient will not be prescribed an antibiotic. Rationale 3: The patient will not be prescribed an antiviral medication. Rationale 4: The patient will not be prescribed an antifungal medication. Global Rationale: 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. The patient experiencing an allergic response to ragweed will not be prescribed an antibiotic, antiviral, or antifungal medication. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 304 Question 20 Type: MCMA A patient diagnosed with rheumatoid arthritis is not responding to NSAID therapy. The nurse anticipates that which medications and therapies will be considered for this patient’s treatment? Standard Text: Select all that apply. 1. gold salt 2. plasmapheresis 3. methotrexate (Rheumatrex) 4. infliximab (Remicade)
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
5. corticosteroids Correct Answer: 3, 4, 5 Rationale 1: Gold salt is not an option to treat the patient with rheumatoid arthritis. Rationale 2: Plasmapheresis may or may not be indicated for this patient. Rationale 3: Methotrexate (Rheumatrex) may be used to inhibit immune responses in autoimmune disorders. Rationale 4: Infliximab (Remicade) reduces the inflammatory process in autoimmune disorders. Rationale 5: Corticosteroids may be prescribed to reduce the inflammatory response and minimize tissue damage. Global Rationale: Methotrexate (Rheumatrex) may be used to inhibit immune responses in autoimmune disorders. Infliximab (Remicade) reduces the inflammatory process in autoimmune disorders. Corticosteroids may be prescribed to reduce the inflammatory response and minimize tissue damage. Gold salt is not an option to treat the patient with rheumatoid arthritis. Plasmapheresis may or may not be indicated for this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 307 Question 22 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: This is not a normal reaction to the medication. Rationale 3: These are not signs of impending organ failure. Rationale 4: These are not signs that the transplanted organ is beginning to function. Global Rationale: 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. This is not a normal reaction to the medication. These are not signs of impending organ failure or signs that the transplanted organ is beginning to function. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 311 Question 23 Type: MCSA A patient diagnosed with AIDS complains of 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)
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: Megestrol (Megace) can be prescribed to increase the patient’s appetite and promote weight gain. Rationale 2: Ciprofloxacin (Cipro) is an anti-infective medication. Rationale 3: Zidovudine (Retrovir, AZT) is an antiretroviral agent. Rationale 4: Abacavir (Ziagen) is a potent inhibitor of reverse transcriptase. Global Rationale: Megestrol (Megace) can be prescribed to increase the patient’s appetite and promote weight gain. Ciprofloxacin (Cipro) is an anti-infective medication, zidovudine (Retrovir, AZT) is an antiretroviral agent, and abacavir (Ziagen) is a potent inhibitor of reverse transcriptase. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.3. Examine the treatment options for the human immunodeficiency virus. Page Number: 329 Question 24 Type: MCSA The nurse is instructing a patient diagnosed 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 Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 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. Global Rationale: A high-protein, high-kilocalorie diet provides the necessary nutrients to meet metabolic and tissue healing needs. The meal with the most calories is the spaghetti and meat sauce, vanilla milkshake made with Ensure, and pecan pie. The other meals have fewer calories. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.4. Utilize the nursing process in care of client. Page Number: 329 Question 25 Type: MCSA A patient diagnosed 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. Correct Answer: 1 Rationale 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The patient’s current prescribed medication is not effective. Rationale 3: The patient’s medication dose should not be reduced. Rationale 4: This laboratory value does not indicate toxicity. Global Rationale: 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. The patient’s current prescribed medication is not effective. This laboratory value does not indicate that the dose can be reduced or that the medication is toxic. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.3. Examine the treatment options for the human immunodeficiency virus. Page Number: 321 Question 26 Type: MCSA 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.” Correct Answer: 1 Rationale 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. Rationale 2: The patient is also correct about having to practice safe sex with a partner. Rationale 3: The patient is correct in stating that it is not an acceptable practice to share toothbrushes or razors. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The patient is also correct in stating that blood donation is prohibited. Global Rationale: 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. The patient is correct in stating that it is not an acceptable practice to share toothbrushes or razors, that blood donation is prohibited, and that he and his partner must practice safe sex. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.4. Utilize the nursing process in care of client. Page Number: 329 Question 27 Type: MCSA 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. Correct Answer: 2 Rationale 1: Epinephrine may be administered after another step is performed. Rationale 2: Establishing and maintaining a patent airway is of primary importance when a patient demonstrates anaphylactic shock. Rationale 3: The patient can be reassured after the other interventions have been performed. Rationale 4: A cardiac monitor may be connected after another step is performed. Global Rationale: Establishing and maintaining a patent airway is of primary importance when a patient demonstrates anaphylactic shock. After an airway is established, epinephrine may be administered and a cardiac monitor connected. The patient can be reassured after the other interventions have been performed. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 305 Question 28 Type: MCSA A patient tells the nurse, “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?” Correct Answer: 3 Rationale 1: The nurse should not compound the patient’s anxiety by appearing to assume the patient will lose health benefits. Rationale 2: The nurse should not compound the patient’s anxiety by appearing to assume the patient will lose the job. Rationale 3: The onset of an autoimmune disorder is frequently associated with an abnormal stressor, either physical or psychological. Autoimmune disorders are frequently progressive relapsing–remission disorders characterized by periods of exacerbation and remission. Rationale 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. Global Rationale: The onset of an autoimmune disorder is frequently associated with an abnormal stressor, either physical or psychological. Autoimmune disorders are frequently progressive relapsing–remission disorders LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
characterized by periods of exacerbation and remission. The nurse should not compound the patient’s anxiety by appearing to assume the patient will lose the job or health benefits. 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. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss the characteristics of immunodeficiencies. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 307 Question 29 Type: MCSA A patient with an autoimmune disorder tells the nurse, “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 Correct Answer: 1 Rationale 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. Rationale 2: There is no evidence that the patient is experiencing an alteration in body functions. Rationale 3: There is no evidence that the patient is unable to cope with the health problem. Rationale 4: There is no evidence that the patient is unable to tolerate activity. Global Rationale: 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. There is no evidence LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
that the patient is experiencing an alteration in body functions, is unable to cope with the health problem, or is unable to tolerate activity. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Diagnosis Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 307
Question 30 Type: MCSA 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. Correct Answer: 3 Rationale 1: The use of this medication does not indicate that the patient will have a shorter recovery time. Rationale 2: There is no evidence that this medication has fewer adverse effects. Rationale 3: Because of significant side effects, the use of OKT3, a monoclonal antibody, is limited primarily to treatment of steroid-resistant rejection. Rationale 4: There is no evidence to suggest that the patient is at risk for developing a graft infection. Global Rationale: Because of significant side effects, the use of OKT3, a monoclonal antibody, is limited primarily to treatment of steroid-resistant rejection. The use of this medication does not indicate that the patient will have a shorter recovery time. There is no evidence that this medication has fewer adverse effects or that the patient is at risk for developing a graft infection. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.3.3. Examine the diagnosis and medications used to treat tissue transplantation and rejection. Page Number: 311 Question 31 Type: MCSA 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 Correct Answer: 4 Rationale 1: These symptoms do not indicate a reaction to the medication. Rationale 2: These symptoms do not indicate the development of an opportunistic infection. Rationale 3: These symptoms do not indicate the development of a secondary cancer. Rationale 4: Peripheral nervous system manifestations are common in HIV-infected patients. Sensory neuropathies with manifestations of numbness, tingling, and pain in the lower extremities affect about 30% of patients with AIDS. Global Rationale: Peripheral nervous system manifestations are common in HIV-infected patients. Sensory neuropathies with manifestations of numbness, tingling, and pain in the lower extremities affect about 30% of patients with AIDS. The manifestations noted are not consistent with a medication reaction, opportunistic infection, or secondary cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Evaluation Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.2. Differentiate the manifestations and diagnostic tests for human immunodeficiency virus. Page Number: 318 Question 32 Type: MCSA A young female patient with HIV does not want to see the gynecologist because, she says, “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.” Correct Answer: 1 Rationale 1: Cervical cancer develops frequently in women with HIV infection and tends to be aggressive. Women with concurrent HIV infection and cervical cancer usually die of the cervical cancer, not AIDS. Because of this, it is recommended that women with HIV infection have Papanicolaou (Pap) smears every 6 months and aggressive treatment of cervical dysplasia with colposcopic examination and cone biopsy. Rationale 2: While the nurse should investigate the patient’s feelings, the emphasis is on preventive treatments. Rationale 3: The gynecologist does not focus on the diagnosis of Hodgkin disease. Rationale 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. Global Rationale: Cervical cancer develops frequently in women with HIV infection and tends to be aggressive. Women with concurrent HIV infection and cervical cancer usually die of the cervical cancer, not AIDS. Because of this, it is recommended that women with HIV infection have Papanicolaou (Pap) smears every 6 months and aggressive treatment of cervical dysplasia with colposcopic examination and cone biopsy. While the nurse should LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
investigate the patient’s feelings, the emphasis is on preventive treatments. The gynecologist does not focus on the diagnosis of Hodgkin disease. 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. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.2. Differentiate the manifestations and diagnostic tests for human immunodeficiency virus. Page Number: 320 Question 33 Type: MCSA 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. Correct Answer: 2 Rationale 1: Confronting the patient would lead to alienation. Rationale 2: Provider–patient relationships seem to have the most influence on adherence behavior. Rationale 3: There is nothing in the question to suggest that nausea is a side effect of the medication. Rationale 4: There is no reason to assume that the noncompliance is due to a financial reason. Global Rationale: Provider–patient relationships seem to have the most influence on adherence behavior. Confronting the patient would lead to alienation. There is nothing in the question to suggest that nausea is a side effect of the medication. There is no reason to assume that the noncompliance is due to a financial reason. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.4.4. Utilize the nursing process in care of client. Page Number: 322 Question 34 Type: MCSA 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. Correct Answer: 4 Rationale 1: Condoms have risks associated with their use during sexual activity. Rationale 2: Testing for HIV every 6 months is unrealistic and will not prevent contracting the virus. Rationale 3: Sex can be safe. Rationale 4: Safe sex practices include no sex, long-term mutually monogamous sexual relations between two uninfected people, and mutual masturbation without direct contact. Global Rationale: All sexually active individuals need to know how HIV is spread. Safe sex practices include no sex, long-term mutually monogamous sexual relations between two uninfected people, and mutual masturbation without direct contact. Condoms have risks associated with their use during sexual activity. Testing for HIV every 6 months is unrealistic and will not prevent contracting the virus. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.4.4. Utilize the nursing process in care of client. Page Number: 325 Question 35 Type: MCMA 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? Standard Text: 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. Correct Answer: 2, 5 Rationale 1: For vaginal or anal sex, the condom should be lubricated with the spermicidal agent nonoxynol-9 for additional protection. Rationale 2: Sex should be practiced only after learning the partner’s HIV status. Rationale 3: Oral birth control pills do not reduce the transmission of HIV. Rationale 4: Using an oil-based lubricant such as petroleum jelly can result in condom damage; water-based lubricants are acceptable. Rationale 5: People who use intravenous drugs should never share needles, syringes, or other drug paraphernalia. Global Rationale: Sex should be practiced only after learning the partner’s HIV status. People who use intravenous drugs should never share needles, syringes, or other drug paraphernalia. For vaginal or anal sex, the condom should be lubricated with the spermicidal agent nonoxynol-9 for additional protection. Oral birth control LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
pills do not reduce the transmission of HIV. Using an oil-based lubricant such as petroleum jelly can result in condom damage; water-based lubricants are acceptable. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.4.4. Utilize the nursing process in care of client. Page Number: 325 Question 36 Type: MCMA A patient is diagnosed with a type I hypersensitivity reaction. The nurse recognizes that which chemical mediators caused the patient’s symptoms? Standard Text: Select all that apply. 1. histamine 2. complement 3. autoantibodies 4. erythrocytes 5. kinins Correct Answer: 1,2,5 Rationale 1: Histamine is a chemical mediator released by the mast cells in a Type I hypersensitivity reaction. Rationale 2: Complement is a chemical mediator released by the mast cells in a Type I hypersensitivity reaction. Rationale 3: Autoantibodies are not released by the mast cells in a Type I hypersensitivity reaction. Rationale 4: Erythrocytes are not released by the mast cells in a Type I hypersensitivity reaction. Rationale 5: Kinins are chemical mediators released by the mast cells in a Type I hypersensitivity reaction. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Histamine, complement, and kinins are chemical mediators released by the mast cells in a Type I hypersensitivity reaction. Autoantibodies and erythrocytes are not released by the mast cells in a Type I hypersensitivity reaction. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 299 Question 37 Type: MCSA The nurse is reviewing assessment data for several patients who are suspected of exposure to HIV. Which patients demonstrate findings consistent with HIV exposure?
1. Patients A and C LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Patient A only 3. Patients B and D 4. Patient C only Correct Answer: 2 Rationale 1: For one of these patients, ELISA and Western Blot + tests were negative. Rationale 2: ELISA and Western Blot + is indicative of seroconversion for HIV. A slight decrease in CD4 may also be present at this time. Most patients develop an acute mononucleosis-type illness within days to weeks after contracting the virus. Typical manifestations include fever, sore throat, arthralgias and myalgias, headache, and rash. Rationale 3: These patients’ ELISA and Western Blot + tests were negative. Rationale 4: This patient’s ELISA and Western Blot + tests were negative. Global Rationale: Patient A’s ELISA and Western Blot + tests were positive. ELISA and Western Blot + is indicative of seroconversion for HIV. A slight decrease in CD4 may also be present at this time. Most patients develop an acute mononucleosis-type illness within days to weeks after contracting the virus. Typical manifestations include fever, sore throat, arthralgias and myalgias, headache, and rash. The other patients’ ELISA and Western Blot + tests were negative. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.2. Differentiate the manifestations and diagnostic tests for human immunodeficiency virus. Page Number: 321 Question 38 Type: MCSA The nurse on the transplant unit is reviewing assessment data for a group of patients. Which patients should the nurse realize are at greatest risk for graft-versus-host disease?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Patients A and C 2. Patient A only 3. Patient B only 4. Patient D only Correct Answer: 3 Rationale 1: Graft-versus-host disease (GVHD) is a potentially fatal complication of stem cell transplantation to immunocompromised patients. Rationale 2: Acute GVHD occurs within the first 100 days following a transplant and primarily affects the skin, liver, and gastrointestinal tract. Rationale 3: Graft-versus-host disease (GVHD) is a potentially fatal complication of stem cell transplantation to immunocompromised patients. Acute GVHD occurs within the first 100 days following a transplant and primarily affects the skin, liver, and gastrointestinal tract. The patient develops a maculopapular pruritic rash beginning on the palms of the hands and soles of the feet. The rash may spread to involve the entire body and lead to desquamation. Gastrointestinal manifestations include abdominal pain, nausea, and bloody diarrhea. GVHD that lasts longer than 100 days is said to be chronic. If it is limited to the skin and liver, the prognosis is good. If multiple organs are involved, the prognosis is poor. Rationale 4: Graft-versus-host disease (GVHD) is a potentially fatal complication of stem cell transplantation to immunocompromised patients. Global Rationale: Graft-versus-host disease (GVHD) is a potentially fatal complication of stem cell transplantation to immunocompromised patients. Acute GVHD occurs within the first 100 days following a transplant and primarily affects the skin, liver, and gastrointestinal tract. The patient develops a maculopapular pruritic rash beginning on the palms of the hands and soles of the feet. The rash may spread to involve the entire body and lead to desquamation. Gastrointestinal manifestations include abdominal pain, nausea, and bloody diarrhea. GVHD that lasts longer than 100 days is said to be chronic. If it is limited to the skin and liver, the prognosis is good. If multiple organs are involved, the prognosis is poor. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the pathophysiology of autoimmune disorders and tissue transplant rejection. MNL Learning Outcome: 2.3.2. Differentiate the manifestations of tissue transplantation and rejection. Page Number: 309 Question 39 Type: MCSA The nurse is reviewing assessment data for a group of patients. Which patient’s findings are consistent with a Type II cytotoxic hypersensitivity reaction?
1. Patient A 2. Patient B 3. Patient C 4. Patient D
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 4 Rationale 1: This patient is more likely to experience type I immediate hypersensitivity. Rationale 2: There is no evidence that this patient will develop any type of hypersensitivity. Rationale 3: Latex allergy is a type IV delayed hypersensitivity reaction. Rationale 4: A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. IgG or IgM type antibodies are formed to a cell-bound antigen such as the ABO or Rh antigen. When these antibodies bind with the antigen, the complement cascade is activated, resulting in destruction of the target cell. Global Rationale: A hemolytic transfusion reaction to blood of an incompatible type is characteristic of a type II or cytotoxic hypersensitivity reaction. IgG or IgM type antibodies are formed to a cell-bound antigen such as the ABO or Rh antigen. When these antibodies bind with the antigen, the complement cascade is activated, resulting in destruction of the target cell. The other patients are not demonstrating signs of a type II hypersensitivity reaction. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.2. Differentiate the manifestations of hypersensitivity reactions. Page Number: 301 Question 40 Type: MCSA The nurse is determining which assigned patients might be experiencing an immunodeficiency. Which patient or patients should the nurse identify as having this health problem?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Patient A only 2. Patient D only 3. All patients 4. Patient B and C Correct Answer: 3 Rationale 1: These manifestations indicate immunosuppression caused by HIV/AIDS. Rationale 2: These manifestations are consistent with immunosuppression from rheumatoid arthritis. Rationale 3: All the patients are demonstrating manifestations of immunodeficiency. Patient A’s manifestations are a consistent with immunosuppression from HIV/AIDS. Patient B’s manifestations are consistent with SLE. Patient C’s manifestations are consistent with AIDS. Patient D’s manifestations are consistent with rheumatoid arthritis. Rationale 4: Patient B’s manifestations are consistent with SLE. Patient C’s manifestations are consistent with AIDS. Global Rationale: All the patients are demonstrating manifestations of immunodeficiency. Patient A’s manifestations are a consistent with immunosuppression from HIV/AIDS. Patient B’s manifestations are LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
consistent with SLE. Patient C’s manifestations are consistent with AIDS. Patient D’s manifestations are consistent with rheumatoid arthritis. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss the characteristics of immunodeficiencies. MNL Learning Outcome: 2.2.1. Explain the causes, theories, and pathophysiology of immunodeficiency in the older client. Page Number: 306, 316 Question 41 Type: MCHS A patient is scheduled for allergy testing. Place an “X” over the area of the body best suited for prick or intradermal testing.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Epicutaneous testing (prick testing) is generally done first to avoid a systemic reaction; it may be followed by intradermal testing of allergens with a negative response to prick testing. The forearm or intrascapular area is used for intradermal testing. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 304 Question 42 Type: SEQ When considering guidelines for safer sex teaching, how should the nurse rank the risk for HIV transmission from highest to lowest? Standard Text: Click and drag the options below to move them up or down. Choice 1. heterosexual intercourse between partners using latex condoms Choice 2. abstinence LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Choice 3. monogamous sex between partners who are both ELISA and Western Blot negative Choice 4. anal intercourse between partners using latex condoms Correct Answer: 4, 1, 3, 2 Rationale 1: Heterosexual intercourse between partners using latex condoms is the second-riskiest behavior of these choices. Rationale 2: Abstinence is the safest practice. Rationale 3: Monogamous sex between partners who are both ELISA and Western Blot negative still carries some small risk. Rationale 4: Anal intercourse is damaging to sensitive tissues, thereby increasing trauma and risk of transmission. Global Rationale: Anal intercourse is damaging to sensitive tissues, thereby increasing trauma and risk of transmission. Heterosexual intercourse between partners using latex condoms is the second riskiest behavior of these choices. Monogamous sex between partners who are both ELISA and Western Blot negative still carries some small risk. Abstinence is the safest practice. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.1.3. Examine the diagnosis and treatment of hypersensitivity reactions. Page Number: 325 Question 43 Type: MCMA The nurse is preparing to instruct a patient with hypersensitivity reactions to bee stings. What should the nurse include in this teaching? Standard Text: Select all that apply. 1. Wear a Medic-alert bracelet identifying the allergy at all times. 2. Carry an epinephrine pen at all times. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. Wear long-sleeved clothing while outdoors. 4. Minimize exposure by staying indoors. 5. Take an antihistamine prior to going outdoors. Correct Answer: 1, 2, 3 Rationale 1: This patient should wear a Medic-alert bracelet identifying the patient’s allergy at all times. Rationale 2: This patient should carry an epinephrine pen at all times. Rationale 3: This patient should wear long sleeves while outdoors. Rationale 4: It is not necessary for the patient to stay indoors. Rationale 5: It is not necessary to take an antihistamine prior to going outside. Global Rationale: This patient should wear a Medic-alert bracelet identifying allergy, carry an epinephrine pen at all times, and wear long sleeves while outdoors. It is not necessary for the patient to stay indoors or take an antihistamine prior to going outside. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 305 Question 44 Type: MCMA The nurse is preparing to see patients who are HIV positive in the clinic. Which patients should the nurse realize are at greatest risk for developing AIDS-associated secondary cancers? Standard Text: Select all that apply. 1. men who have sex with men
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. heterosexual couples who are monogamous 3. women with cervical dysplasia 4. HIV-positive patients with Mycobacterium avium complex 5. HIV patients who have recently seroconverted Correct Answer: 1, 3 Rationale 1: HIV-positive men who have sex with men have an increased risk of developing AIDS-associated secondary cancers. Rationale 2: HIV-positive monogamous heterosexual couples do not have an increased risk of developing AIDSassociated secondary cancers. Rationale 3: HIV-positive women with cervical dysplasia have an increased risk of developing AIDS-associated secondary cancers. Rationale 4: HIV-positive patients with Mycobacterium avium complex do not have an increased risk of developing AIDS-associated secondary cancers. Rationale 5: HIV patients who have recently seroconverted do not have an increased risk of developing AIDSassociated secondary cancers. Global Rationale: HIV-positive men who have sex with men, as well as HIV-positive women with cervical dysplasia, have an increased risk of developing AIDS-associated secondary cancers. HIV-positive monogamous heterosexual couples, HIV-positive patients with Mycobacterium avium complex, and HIV patients who have recently seroconverted do not have an increased risk of developing AIDS-associated secondary cancers. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.1. Explain the risk factors and pathophysiology of human immunodeficiency virus. Page Number: 319-320 Question 45 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is planning care for an older patient. Which factors does the nurse realize are affecting this patient’s immune status? Standard Text: Select all that apply. 1. environmental pollution 2. a chronic illness 3. presence of autoantibodies 4. nutritional status 5. quality of sleep and rest Correct Answer: 1, 2, 3, 4 Rationale 1: Environmental pollution affects the older person’s immune status. Rationale 2: Chronic diseases affect the older person’s immune status. Rationale 3: Autoantibodies affect the older person’s immune status. Rationale 4: Nutritional status affects the older person’s immune status. Rationale 5: Quality of rest and sleep are not identified as affecting the older person’s immune status. Global Rationale: Environmental pollution, chronic diseases, autoantibodies, and nutritional status all affect the older person’s immune status. Quality of sleep and rest are not identified as affecting the older person’s immune status. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Review the normal immune system function, including self-recognition. MNL Learning Outcome: 2.2.2. Differentiate the normal influences of aging and factors that affect aging of the immune system. Page Number: 298 Question 46 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCMA The nurse is conducting a physical assessment on a patient experiencing a hypersensitivity reaction. On which areas should the nurse focus this assessment? Standard Text: Select all that apply. 1. skin condition 2. mucous membranes 3. peripheral pulses 4. respiratory rate and lung sounds 5. cranial nerve function Correct Answer: 1, 2, 4 Rationale 1: For the patient with a hypersensitivity reaction, the physical assessment should focus on the skin for lesions or rashes. Rationale 2: For the patient with a hypersensitivity reaction, the physical assessment should focus on mucous membranes of nose and mouth. Rationale 3: Peripheral pulses are not specific to immune function. Rationale 4: For the patient with a hypersensitivity reaction, the physical assessment should focus on respiratory rate and adventitious breath sounds. Rationale 5: Cranial nerve function is not specific to immune function. Global Rationale: For the patient with a hypersensitivity reaction, the physical assessment should focus on mucous membranes of nose and mouth, skin for lesions or rashes, eyes (tearing and redness), respiratory rate, and adventitious breath sounds. Peripheral pulses and cranial nerve function are not specific to immune function. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Review the normal immune system function, including self-recognition. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 305 Question 47 Type: MCMA A patient is being treated for an acute hypersensitivity reaction. Which assessment findings indicate that the patient is developing an alteration in cardiac output? Standard Text: 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 Correct Answer: 1, 3, 4, 5 Rationale 1: A change in level of consciousness (lethargy, apprehension, or agitation) is often the first indicator of decreased cardiac output. Rationale 2: Pruritus is not an indication of an alteration in cardiac output. Rationale 3: As cardiac output drops, the glomerular filtration rate (GFR) falls. With an output of less than 30 mL/h, the patient is at risk for acute kidney injury from ischemia. Rationale 4: As cardiac output falls, peripheral vessels constrict and tissue perfusion is impaired. Rationale 5: A fall in blood pressure may indicate shock. Global Rationale: A change in level of consciousness (lethargy, apprehension, or agitation) is often the first indicator of decreased cardiac output. As cardiac output drops, peripheral vessels constrict and tissue perfusion is impaired. The glomerular filtration rate (GFR) also falls; with an output of less than 30 mL/h, the patient is at risk for acute kidney injury from ischemia. A fall in blood pressure may indicate shock. Pruritus is not an indication of an alteration in cardiac output. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the four types of hypersensitivity reactions. MNL Learning Outcome: 2.1.4. Utilize the nursing process in care of client. Page Number: 306 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 48 Type: MCMA The nurse is reviewing a patient’s laboratory results and learns that the patient’s rheumatoid factor titer is 1:30. Which health problems might the patient be experiencing? Standard Text: Select all that apply. 1. Leukemia 2. Renal disease 3. Liver cirrhosis 4. Rheumatoid arthritis 5. Systemic lupus erythematosus Correct Answer: 1, 2, 3 Rationale 1: A rheumatoid factor titer between 1:20 and 1:80 may be present in leukemia. Rationale 2: A rheumatoid factor titer between 1:20 and 1:80 may be present in renal disease. Rationale 3: A rheumatoid factor titer between 1:20 and 1:80 may be present in liver cirrhosis. Rationale 4: A rheumatoid factor titer of 1:80 or higher indicates rheumatoid arthritis. Rationale 5: A rheumatoid factor is not diagnostic for systemic lupus erythematosus. Global Rationale: Titers between 1:20 and 1:80 may be present in autoimmune disorders and diseases such as leukemia, liver cirrhosis, and renal disease. A rheumatoid factor titer of 1:80 or higher indicates rheumatoid arthritis. A rheumatoid factor is not diagnostic for systemic lupus erythematosus. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 5. Identify laboratory and diagnostic tests used to diagnose and monitor immune response. MNL Learning Outcome: 2.2.4. Utilize the nursing process in care of client. Page Number: 307 Question 49 Type: MCMA A patient is prescribed to receive lymphocyte immune globulin (Atgam) to prevent an immediate transplant reaction. What actions should the nurse take when administering this medication? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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 Correct Answer: 2, 3, 5 Rationale 1: The nurse should monitor for serum sickness by analyzing renal function studies. Hourly urine output measurements are not necessary. Rationale 2: Because of the risk for anaphylactic reactions, epinephrine should be kept at the bedside. Rationale 3: Acetaminophen is used to premedicate the patient prior to receiving this medication. Rationale 4: The medication is to be infused through a central line over 4 to 6 hours. Rationale 5: Vital signs are to be measured every hour while the medication is infusing. Global Rationale: Because of the risk for anaphylactic reactions, epinephrine should be kept at the bedside. Acetaminophen is used to premedicate the patient prior to receiving this medication. Vital signs are to be measured every hour while the medication is infusing. The nurse should monitor for serum sickness by analyzing renal function studies. Hourly urine output measurements are not necessary. The medication is to be infused through a central line over 4 to 6 hours. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.3.3. Examine the diagnosis and medications used to treat tissue transplantation and rejection. Page Number: 313 Question 50 Type: MCMA A patient with HIV is being treated with the protease inhibitor atazanavir (Reyataz). Which effects should the nurse expect the patient to experience while taking this medication? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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 Correct Answer: 2, 4, 5 Rationale 1: Abdominal obesity is not associated with atazanavir (Reyataz). Rationale 2: Atazanavir (Reyataz) is effective in reducing viral load. Rationale 3: Skeletal muscle wasting is not associated with atazanavir (Reyataz). Rationale 4: Atazanavir (Reyataz) is usually well tolerated by patients. Rationale 5: Atazanavir (Reyataz) has a beneficial effect on lipids. Global Rationale: Atazanavir (Reyataz) has a beneficial effect on lipids, is effective in reducing viral load, and is usually well tolerated by patients. Other protease inhibitors can cause abdominal obesity and skeletal muscle wasting. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 6. Describe interdisciplinary therapies and medications used to treat patients with altered immunity. MNL Learning Outcome: 2.4.3. Examine the treatment options for the human immunodeficiency virus. Page Number: 322 Question 51 Type: MCMA A patient who engages in high-risk sexual behavior is urged to have total knee replacement surgery. What actions should the patient consider prior to scheduling this surgery? Standard Text: Select all that apply. 1. Delay the surgery for 1 year 2. Schedule the surgery immediately 3. Begin medication therapy for HIV LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Consider autologous transfusions for the surgery 5. Have testing for HIV in 6 months Correct Answer: 4, 5 Rationale 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. Rationale 2: The surgery should not be scheduled until the patient’s HIV status is determined. Rationale 3: There is no evidence to support the implementation of HIV medication therapy. Rationale 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. When possible, patients should be encouraged to use autologous transfusion, donating their own blood prior to an anticipated surgery. Rationale 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, 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. Global Rationale: Patients in the window period between contraction of the virus and the development of detectable antibodies are able to transmit the virus to others. This window period usually lasts from 6 weeks to 6 months. The patient should be tested in 6 months. When possible, patients should be encouraged to use autologous transfusion, donating their own blood prior to an anticipated surgery. The surgery should not be scheduled until the patient’s HIV status is determined. Rarely does it take 1 year to determine if a patient is HIV positive. There is no evidence to support the implementation of HIV medication therapy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 7. Correlate the pathophysiologic alterations with the manifestations of HIV/AIDS infection. MNL Learning Outcome: 2.4.4. Utilize the nursing process in care of client. Page Number: 326
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 14 Question 1 Type: MCSA A patient shows the nurse a new sore on the forearm that has been increasing in size and will not heal. The nurse knows that which sign could also point to a diagnosis of 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 Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. 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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 341
Question 2 Type: MCSA After learning that he has a benign tumor in his abdomen, the patient is overheard telling his wife that he has cancer. What should the nurse say to the patient and spouse? 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.” Correct Answer: 1 Rationale 1: A benign tumor is encapsulated, slow-growing, and once removed, will not recur. Rationale 2: The patient does not have cancer but rather a benign tumor. Rationale 3: Even though benign tumors will not spread to other tissues, the nurse should not refer to the growth as being cancer. Rationale 4: The growth has not invaded other tissues. Global Rationale: A benign tumor is encapsulated, slow-growing, and once removed, will not recur. The patient does not have cancer but rather a benign tumor. Even though benign tumors will not spread to other tissues, the nurse should not refer to the growth as being cancer. The growth has not invaded other tissues. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 341
Question 3 Type: MCSA A patient tells the nurse that he has a benign tumor that has spread into his 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?” Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not tell the patient that benign tumors do not spread. Rationale 3: The nurse should not reinforce the patient’s belief that the tumor is benign. Rationale 4: The patient may or may not know if surgery is indicated to remove the tumor. Global Rationale: 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. The nurse should not tell the patient that benign tumors do not spread. The nurse should not reinforce the patient’s belief that the tumor is benign. The patient may or may not know if surgery is indicated to remove the tumor. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 341 Question 4 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Contact inhibition is a characteristic of benign neoplasms. Rationale 3: A destructive force from a benign neoplasm is when the benign tumor impinges upon a body part, causing damage. Rationale 4: Benign tumors are usually solid masses. Global Rationale: 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. Contact inhibition is a characteristic of benign neoplasms. A destructive force from a benign neoplasm is when the benign tumor impinges upon a body part causing damage. Benign tumors are usually solid masses. Cognitive Level: Applying Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.4. Analyze the mechanisms of tumor invasion and metastasis. Page Number: 341
Question 5 Type: MCSA 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.” Correct Answer: 1 Rationale 1: The theory of cellular mutation suggests that carcinogens cause mutations in cellular DNA, not RNA. Rationale 2: Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics. Inherited cancers can become inactive by deletion or mutation. Rationale 3: The majority of people do not have an inherited form of cancer is a true statement. Rationale 4: Known carcinogens include viruses, drugs, hormones, and chemical and physical agents. Global Rationale: The theory of cellular mutation suggests that carcinogens cause mutations in cellular DNA, not RNA. Oncogenes are genes that promote cell proliferation and are capable of triggering cancerous characteristics. The majority of people do not have an inherited form of cancer is a true statement. Known carcinogens include viruses, drugs, hormones, and chemical and physical agents. Cognitive Level: Applying Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 334, 339
Question 6 Type: MCSA A patient with a history of smoking is diagnosed with cancer. If applying the cellular mutation theory of cancer to this patient’s diagnosis, the nurse realizes that smoking impacted which stage? 1. promotion 2. initiation 3. progression 4. replication Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: In the progression stage further inherited changes acquired during the cell replication develop into a cancer. Rationale 4: Replication is not a stage in the mutation theory of cancer. Global Rationale: 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. The initiation stage involves LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
permanent damage in the cellular DNA as a result of exposure to a carcinogen that was not repaired or had a defective repair. Promotion may last for years and includes conditions, such as smoking or alcohol use, that act repeatedly on the already affected cells. In the progression stage further inherited changes acquired during the cell replication develop into a cancer. Replication is not a stage in the mutation theory of cancer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 339
Question 7 Type: MCSA A female patient asks the nurse why she needs a procedure to remove part of her cervix that was infected with a virus. 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. Correct Answer: 1 Rationale 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. Rationale 2: There is no medication available to treat the human papillomavirus. Rationale 3: Untreated human papillomavirus can cause melanoma, cervical, penile, and laryngeal cancer. Rationale 4: Untreated human papillomavirus can cause melanoma, cervical, penile, and laryngeal cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. There is no medication available to treat the human papillomavirus. Untreated human papillomavirus can cause melanoma, cervical, penile, and laryngeal cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 340
Question 8 Type: MCSA A patient with a history of using recreational cocaine tells the nurse that he would rather be addicted to cocaine than be diagnosed with cancer. What should the nurse respond with 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.” Correct Answer: 1 Rationale 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 with to the patient. Rationale 2: The nurse should not minimize the patient’s comment by replying about preferences. Rationale 3: People who use cocaine do not have a lower risk of developing cancer. Rationale 4: There is no evidence that the purity of cocaine prevents the development of cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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 respond with to the patient. The nurse should not minimize the patient’s comment by replying about references. People who use cocaine do not have a lower risk of developing cancer. There is no evidence that the purity of cocaine prevents the development of cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 340
Question 9 Type: MCMA A college student is diagnosed with Epstein-Barr virus. The student has a history of smoking and recreational cocaine use and works for a floor refinishing company part-time. Which factors increase this student’s risk for developing cancer? Standard Text: Select all that apply. 1. drug use 2. occupation 3. smoking 4. viral infection 5. age Correct Answer: 1, 2, 3, 4 Rationale 1: Some recreational drugs are also implicated as carcinogens. Immunosuppressant promoters include heroin and cocaine. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 3: Benzopyrene found in cigarette smoke contributes to the development of cancer. Rationale 4: Several viruses have been associated with the development of cancer. These viruses include EpsteinBarr. Rationale Rationale 5: The patient’s young age is not a risk factor for the development of cancer. Global Rationale: Some recreational drugs are also implicated as carcinogens. Immunosuppressant promoters include heroin and cocaine. 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. Benzopyrene found in cigarette smoke contributes to the development of cancer. Several viruses have been associated with the development of cancer. These viruses include Epstein-Barr. The patient’s young age is not a risk factor for the development of cancer. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 340
Question 10 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. an Hispanic man 4. an Hispanic woman Correct Answer: 1 Rationale 1: African Americans have the highest mortality rate for all cancers and major cancers among all ethnic groups. Rationale 2: Cancer incidence and mortality are lower in Native American men and women than in any other ethnic or racial group. Rationale 3: Hispanics have higher rates of cancers associated with infectious agents, such as uterine, cervix, liver, and stomach cancer. Rationale 4: Hispanics have higher rates of cancers associated with infectious agents, such as uterine, cervix, liver, and stomach cancer. Global Rationale: African Americans have the highest mortality rate for all cancers and major cancers among all ethnic groups. Cancer incidence and mortality are lower in Native American men and women than in any other ethnic or racial group. Hispanics have higher rates of cancers associated with infectious agents, such as uterine, cervix, liver, and stomach cancer. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 336
Question 11 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 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 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 that may lead to the development of cancer. Rationale 2: This patient has fewer risk factors than the first patient. Rationale 3: This patient has fewer risk factors than the first patient. Rationale 4: This patient has fewer risk factors than the first patient. Global Rationale: 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 that may lead to the development of cancer. The other patients have fewer risk factors for the development of cancer. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 336
Question 12 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A female patient tells the nurse that she does not want to have annual mammograms because the x-rays can cause cancer. How should the nurse respond to this patient? 1. “Breast cancer is the number one type of cancer in females. The risk of developing cancer from the x-rays is considerably lower than the risk of having undiagnosed breast cancer.” 2. “I don’t blame you. X-rays do cause cancer.” 3. “Be sure to do monthly breast exams.” 4. “Contact your doctor if you notice any breast changes, feel any lumps, or develop breast pain since these are all symptoms of active breast cancer.” Correct Answer: 1 Rationale 1: The nurse should respond by saying that breast cancer is the number one type of cancer in females and that the risk of developing cancer from x-rays is considerably lower than the risk of having undiagnosed breast cancer. Rationale 2: The nurse should not support the patient’s belief that x-rays cause cancer. Rationale 3: The nurse should instruct the patient to perform monthly breast self-examinations; however, that is not the best response in this situation. Monthly breast examinations should not be used in place of routine mammograms. Rationale 4: Breast changes, lumps, and breast pain are not definitive symptoms of breast cancer. Global Rationale: The nurse should respond by saying that breast cancer is the number one type of cancer in females and that the risk of developing cancer from x-rays is considerably lower than the risk of having undiagnosed breast cancer. The nurse should not support the patient’s belief that x-rays cause cancer. The nurse should instruct the patient to perform monthly breast self-examinations; however, that is not the best response in this situation. Monthly breast examinations should not be used in place of routine mammograms. Breast changes, lumps, and breast pain are not definitive symptoms of breast cancer. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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 health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 336
Question 13 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Simplified metabolic activities are a characteristic of malignant cells. The work of malignant cells is simpler than that of normal cells. Rationale 2: Malignant cells do not perform typical cellular functions. Rationale 3: Rarely does a malignant neoplasm revert to a benign state. Rationale 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. Global Rationale: Simplified metabolic activities are a characteristic of malignant cells. The work of malignant cells is simpler than that of normal cells. Malignant cells loose specialization and differentiation. Malignant cells do not perform typical cellular functions. The transformation into a malignant cell is irreversible. Rarely does a malignant neoplasm revert to a benign state. 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. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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 health promotion/disease prevention strategies; apply health policy Nursing/Integrated Concepts: Nursing Process: Evaluation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 341
Question 14 Type: MCSA A patient diagnosed with an 8 cm tumor in the ascending colon asks the nurse 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.” Correct Answer: 1 Rationale 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. Rationale 2: The response that the tumor cells bound to the tissue within the colon explains how the tumor became established in the colon. Rationale 3: The response about tumor cells moving about freely explains metastasis. Rationale 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. Global Rationale: 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. The response that the tumor cells bound to the tissue within the colon explains how the tumor became established in the colon. The response about tumor cells moving about freely explains metastasis. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 342
Question 15 Type: MCSA A patient is diagnosed with hyperplasia of lung tissue. The nurse realizes that this patient’s first course of treatment will most likely include: 1. identification and removal of the irritant causing the hyperplasia. 2. antibiotic therapy. 3. chemotherapy. 4. radiation therapy. Correct Answer: 1 Rationale 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. Rationale 2: Antibiotic therapy is not a treatment for hyperplasia. Rationale 3: It is not clear whether the patient will need chemotherapy in the future. Rationale 4: It is not clear whether the patient will need radiation therapy in the future. Global Rationale: 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. It is not clear if the patient is going to need chemotherapy or radiation therapy in the future. The first course of treatment is to identify and remove the irritant causing the hyperplasia. Antibiotic therapy is not a treatment for hyperplasia. It is not clear whether the patient will need chemotherapy or radiation therapy in the future. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 339
Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The patient does not have cancer and would not need chemotherapy at this time. Rationale 3: Anaplastic cells of the pancreas would increase this patient’s chances of developing diabetes mellitus. Rationale 4: Anaplastic cells cannot be reversed. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. The patient does not have cancer and would not need chemotherapy at this time. Anaplastic cells of the pancreas would increase this patient’s chances of developing diabetes mellitus. Anaplastic cells cannot be reversed. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 339
Question 17 Type: MCSA 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 Correct Answer: 1 Rationale 1: There are several physical and psychologic effects that occur in a patient diagnosed with cancer. One of these effects is body image concerns. Rationale 2: The patient’s leukocytes are usually decreased, not increased. Rationale 3: Bone pain will depend upon the type of cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: A change in appetite can occur, although is it usually a loss of appetite. Global Rationale: There are several physical and psychologic effects that occur in a patient diagnosed with cancer. One of these effects is body image concerns. The patient’s leukocytes are usually decreased, not increased. Bone pain will depend upon the type of cancer. A change in appetite can occur, although is it usually a loss of appetite. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the physical and psychologic effects of cancer. MNL Learning Outcome: 3.2.1. Analyze the physiological and psychological aspects of cancer. Page Number: 364
Question 18 Type: MCSA A patient with cancer is admitted with a weight loss of 25 lbs. over the last month with progressive anorexia. The nurse suspects this patient is experiencing what physiological effect of cancer? 1. anorexia–cachexia syndrome 2. paraneoplastic syndrome 3. infection 4. esophageal obstruction Correct Answer: 1 Rationale 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. Rationale 2: Paraneoplastic syndromes are indirect effects of cancer. They may be early warning signs of cancer or indicate complications or return of a malignancy. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: An infection caused by cancer does not lead to anorexia. Rationale 4: Esophageal obstruction is not a specific physiological effect of cancer. Global Rationale: 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. Paraneoplastic syndromes are indirect effects of cancer. They may be early warning signs of cancer or indicate complications or return of a malignancy. An infection caused by cancer does not lead to anorexia. Esophageal obstruction is not a specific physiological effect of cancer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the physical and psychologic effects of cancer. MNL Learning Outcome: 3.2.1. Analyze the physiological and psychological aspects of cancer. Page Number: 344
Question 19 Type: MCSA A patient diagnosed with cancer tells the nurse that he does not want to experience anymore pain. What should the nurse do to help this patient? 1. Discuss pain control 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. Correct Answer: 1 Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
knowledge deficit are the major barriers to effective pain management. Because of this, the nurse should discuss pain control options with the patient. Rationale 2: Not every patient with cancer has pain. Rationale 3: Reviewing ways to reduce pain without the use of medication may or may not be appropriate for the patient. Rationale 4: The nurse has no way of knowing whether the patient’s pain will continue throughout treatment. Global Rationale: The pain associated with cancer is usually undertreated because of an inappropriate use of opioids and barriers related to 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 control options with the patient. Not every patient with cancer has pain. Reviewing ways to reduce pain without the use of medication may or may not be appropriate for the patient. The nurse has no way of knowing whether the patient’s pain will continue throughout treatment. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Describe the physical and psychologic effects of cancer. MNL Learning Outcome: 3.2.1. Analyze the physiological and psychological aspects of cancer. Page Number: 345
Question 20 Type: MCSA A patient, diagnosed with cancer, has been receiving radiation treatments to shrink the tumor. After several weeks, the patient tells the nurse that he does not need 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 the radiation. 3. The patient is getting used to having pain. 4. The patient’s pain receptors have been affected by the cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: The tumor is not secreting pain-control chemicals initiated by the radiation. Rationale 3: The patient is not getting used to having pain. Rationale 4: The patient’s pain receptors have not been affected by the cancer. Global Rationale: 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. The tumor is not secreting pain-control chemicals initiated by the radiation. The patient is not getting used to having pain. The patient’s pain receptors have not been affected by the cancer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the physical and psychologic effects of cancer. MNL Learning Outcome: 3.2.1. Analyze the physiological and psychological aspects of cancer. Page Number: 345
Question 21 Type: MCSA 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
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. needle core 4. excisional Correct Answer: 1 Rationale 1: An incisional biopsy is the removal of part of a larger tumor by cutting through the skin. Rationale 2: A fine-needle biopsy uses a very thin needle to aspirate a small amount of tissue from the tumors. Rationale 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. Rationale 4: An excisional biopsy is the removal of an entire tumor through surgery. Global Rationale: An incisional biopsy is the removal of part of a larger tumor by cutting through the skin. A fine-needle biopsy uses a very thin needle to aspirate a small amount of tissue from the tumors. 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. An excisional biopsy is the removal of an entire tumor through surgery. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 4. Describe and compare laboratory and diagnostic tests for cancer. MNL Learning Outcome: 3.2.2. Distinguish tests used in the diagnosis of cancer. Page Number: 351
Question 22 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. ultrasonography Correct Answer: 1 Rationale 1: MRI is the diagnostic tool of choice for both screening and follow-up of cranial and head and neck tumors. Rationale 2: Computed tomography is used in the screening for renal cell and most gastrointestinal tumors. Rationale 3: X-ray imaging is still the method of choice for lung cancer. Rationale 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. Global Rationale: MRI is the diagnostic tool of choice for both screening and follow-up of cranial and head and neck tumors. Computed tomography is used in the screening for renal cell and most gastrointestinal tumors. X-ray imaging is still the method of choice for lung cancer. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Planning Learning Outcome: 4. Describe and compare laboratory and diagnostic tests for cancer. MNL Learning Outcome: 3.2.2. Distinguish tests used in the diagnosis of cancer. Page Number: 348
Question 23 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. calcium Correct Answer: 1 Rationale 1: The acid phosphatase level will be elevated in prostate cancer. Rationale 2: The albumin level will be decreased in malnutrition and metastatic liver cancer. Rationale 3: Bilirubin will be elevated in liver and gallbladder cancer. Rationale 4: Calcium will be elevated in bone cancer and ectopic parathyroid hormone production. Global Rationale: The acid phosphatase level will be elevated in prostate cancer. The albumin level will be decreased in malnutrition and metastatic liver cancer. Bilirubin will be elevated in liver and gallbladder cancer. Calcium will be elevated in bone cancer and ectopic parathyroid hormone production. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Describe and compare laboratory and diagnostic tests for cancer. MNL Learning Outcome: 3.2.2. Distinguish tests used in the diagnosis of cancer. Page Number: 349
Question 24 Type: MCSA A patient’s carcinoembryonic antigen level was initially 16 ng/mL. The level 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. Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: The value would increase if the treatment for cancer were not effective. Rationale 3: This laboratory test cannot determine new sites of cancer. Rationale 4: This laboratory test cannot help determine if the cancer has metastasized. Global Rationale: 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. The value would increase if the treatment for cancer were not effective. This laboratory test cannot determine new sites of cancer or if the cancer has metastasized. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: 4. Describe and compare laboratory and diagnostic tests for cancer. MNL Learning Outcome: 3.2.2. Distinguish tests used in the diagnosis of cancer. Page Number: 349
Question 25 Type: MCSA 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 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.” Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: The main hormones used in cancer therapy are the corticosteroids, which are phase-specific. Rationale 3: Mitotic inhibitors are drugs that act to prevent cell division during the M phase. Rationale 4: Alkylating agents basically act on preformed nucleic acids by creating defects in tumor DNA. Global Rationale: 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. The main hormones used in cancer therapy are the corticosteroids, which are phase specific. Mitotic inhibitors are drugs that act to prevent cell division during the M phase. Alkylating agents basically act on preformed nucleic acids by creating defects in tumor DNA. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the role of chemotherapy in cancer treatment and classify chemotherapeutic agents. MNL Learning Outcome: 3.2.3. Compare chemotherapeutic options for the treatment of cancer. Page Number: 353
Question 26 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 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. Rationale 2: Administering an anti-emetic prior to chemotherapy is not indicated for busulfan (Myleran). Rationale 3: Assessing the oral mucosa is not indicated for busulfan (Myleran). Rationale 4: Monitoring the stool for occult blood is not indicated for busulfan (Myleran). Global Rationale: 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. Administering an anti-emetic prior to chemotherapy, assessing oral mucous membranes, and checking stool for occult blood are not indicated for busulfan (Myleran). Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of chemotherapy in cancer treatment and classify chemotherapeutic agents. MNL Learning Outcome: 3.2.3. Compare chemotherapeutic options for the treatment of cancer. Page Number: 354
Question 27 Type: MCSA A patient diagnosed with breast cancer is receiving 5-Fluorouracil (5-FU). Based on the knowledge of this medication, and anticipated adverse effects or side effects, what action should the nurse perform? 1. Test stool for occult blood. 2. Monitor ECG. 3. Assess lung sounds. 4. Encourage daily fluid intake of 2‒3 liters. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: Assessing for bleeding by checking stool for occult blood is recommended when receiving 5Fluorouracil (5-FU). Rationale 2: Monitoring the ECG is recommended in patients receiving antitumor antibiotics. Rationale 3: Assessing lung sounds is recommended in patients receiving alkylating agents. Rationale 4: Encouraging a daily fluid intake of 2‒3 liters is recommended also for patients receiving alkylating agents. Global Rationale: Assessing for bleeding by checking stool for occult blood is recommended when receiving 5Fluorouracil (5-FU). Monitoring the ECG is recommended in patients receiving antitumor antibiotics. Assessing lung sounds is recommended in patients receiving alkylating agents. Encouraging a daily fluid intake of 2–3 liters is recommended also for patients receiving alkylating agents. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the role of chemotherapy in cancer treatment and classify chemotherapeutic agents. MNL Learning Outcome: 3.2.3. Compare chemotherapeutic options for the treatment of cancer. Page Number: 354
Question 28 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1 Rationale 1: The toxicity of vincristine is characterized by depression of deep tendon reflexes, paresthesias, motor weakness, cranial nerve disruptions, and paralytic ileus. Rationale 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. Rationale 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. Rationale 4: Stomatitis and alopecia are not associated with a toxic reaction to vincristine. Toxic effects of antimetabolites include stomatitis and alopecia. Global Rationale: The toxicity of vincristine is characterized by depression of deep tendon reflexes, paresthesias, motor weakness, cranial nerve disruptions, and paralytic ileus. The worst common toxic side effect of etoposide is hypotension resulting from too rapid intravenous administration. The main toxic effect of antitumor antibiotics is damage to the cardiac muscle. Toxic effects of antimetabolites include stomatitis and alopecia. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Discuss the role of chemotherapy in cancer treatment and classify chemotherapeutic agents. MNL Learning Outcome: 3.2.3. Compare chemotherapeutic options for the treatment of cancer. Page Number: 355
Question 29 Type: MCSA The nurse is caring for a patient undergoing brachytherapy. What personal precautions 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Avoid indirect exposure with radioisotopes containers. Correct Answer: 1 Rationale 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. Rationale 2: If the nurse is pregnant, it is advisable for her to avoid contact with radiation sources. Rationale 3: Maintain the greatest possible distance from the source of radiation. Rationale 4: Avoid direct, not indirect, exposure with radioisotopes containers; for example, do not touch the container. Global Rationale: 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. If pregnant, avoid contact with radiation sources. Maintain the greatest possible distance from the source of radiation. Avoid direct, not indirect, exposure with radioisotopes containers; for example, do not touch the container. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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: Implementation Learning Outcome: 6. Compare and contrast the role of surgery, radiation therapy, and biotherapy in the treatment of cancer. MNL Learning Outcome: 3.2.4. Examine other options for the treatment of cancer. Page Number: 357
Question 30 Type: MCSA 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. decrease in tumor size Correct Answer: 1 Rationale 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. Rationale 2: Kidney function cannot be replaced chemically. Rationale 3: The removal of a kidney would not be done to bypass an obstruction. Rationale 4: The removal of a kidney would not be done to decrease the tumor’s size. Global Rationale: 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. Kidney function cannot be replaced chemically. The removal of a kidney would not be done to bypass an obstruction or to decrease tumor size. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 6. Compare and contrast the role of surgery, radiation therapy, and biotherapy in the treatment of cancer. MNL Learning Outcome: 3.2.4. Examine other options for the treatment of cancer. Page Number: 351
Question 31 Type: MCSA 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 plain water and no soap. 2. Shave the treated area with a straight razor. 3. Apply ice packs to the treatment site to help reduce pain. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Use a sunscreen for three months after the conclusion of the treatments. Correct Answer: 1 Rationale 1: The nurse should instruct the patient to wash the skin that is marked as the radiation site only with plain water, no soap; do not apply deodorant, lotions, medications, perfume, or talcum powder to the site during the treatment period. Rationale 2: If necessary, use only an electric razor to shave the treated area. Rationale 3: Apply neither heat nor cold to the treatment site. Protect skin from sun exposure during treatment and for at least one year after radiation therapy is discontinued. Rationale 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. Global Rationale: The nurse should instruct the patient to wash the skin that is marked as the radiation site only with plain water, no soap; do not apply deodorant, lotions, medications, perfume, or talcum powder to the site during the treatment period. If necessary, use only an electric razor to shave the treated area. Apply neither heat nor cold to the treatment site. Protect skin from sun exposure during treatment and for at least one year after radiation therapy is discontinued. Cover skin with protective clothing during treatment; once radiation is discontinued, use sun-blocking agents with a sun protection factor (SPF) of at least 15. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Compare and contrast the role of surgery, radiation therapy, and biotherapy in the treatment of cancer. MNL Learning Outcome: 3.2.4. Examine other options for the treatment of cancer. Page Number: 359
Question 32 Type: MCSA 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.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 1 Rationale 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. Rationale 2: Brachytherapy is the implantation of radiation into the organ with the cancer. Rationale 3: Photodynamic therapy uses medication that is activated by a laser to treat the cancer. Rationale 4: Peripheral blood stem cell transplantation is used to stimulate or replace nonfunctioning bone marrow. It does not treat cancer. Global Rationale: Biotherapy modifies the biologic processes that result in malignant cells, primarily through enhancing the person’s own immune responses. This is with what the nurse should explain to the patient. Brachytherapy is the implantation of radiation into the organ with the cancer. Photodynamic therapy uses medication that is activated by a laser to treat the cancer. Peripheral blood stem cell transplantation is used to stimulate or replace nonfunctioning bone marrow. It does not treat cancer. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Compare and contrast the role of surgery, radiation therapy, and biotherapy in the treatment of cancer. MNL Learning Outcome: 3.2.4. Examine other options for the treatment of cancer. Page Number: 357
Question 33 Type: MCSA 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? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Administer oxygen. 2. Call the physician. 3. Monitor vital signs. 4. Initiate seizure precautions. Correct Answer: 1 Rationale 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. Rationale 2: Contacting the physician is not the first priority. Rationale 3: Monitoring the patient’s vital signs is important, but it is not the first action to take. Rationale 4: Seizure precautions would not be initiated first. Global Rationale: 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. The nurse should provide oxygen before contacting the physician or monitoring vital signs. Seizure precautions would not be initiated first. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Explain causes and discuss the nursing interventions for common oncologic emergencies. MNL Learning Outcome: 3.3.3. Critique interventions appropriate for the client with cancer. Page Number: 368 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 34 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Confusion is associated with septic shock, but cardiac dysrhythmias and increased urine output are not. Rationale 3: Hypotension, not hypertension, and confusion are associated with septic shock. Increased urine output is not. Rationale 4: Subnormal temperatures can be associated with septic shock, but cardiac dysrhythmias and thirst are not. Global Rationale: 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. Cardiac dysrhythmias, increased urine output, hypertension, and thirst are not usual signs of septic shock. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Explain causes and discuss the nursing interventions for common oncologic emergencies. MNL Learning Outcome: 3.3.3. Critique interventions appropriate for the client with cancer. Page Number: 368
Question 35 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Providing intravenous fluids is not the priority. Rationale 3: Providing oxygen is not the priority. Rationale 4: Turning and repositioning every two hours is not the priority. Global Rationale: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. The patient should be assessed for spinal cord compression and not provided with intravenous fluids, oxygen, or turned and repositioned every two hours. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Explain causes and discuss the nursing interventions for common oncologic emergencies. MNL Learning Outcome: 3.3.3. Critique interventions appropriate for the client with cancer. Page Number: 368-369
Question 36 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Spinal cord compression does not cause renal failure. Rationale 3: Urethral strictures from radiation would not cause renal failure. Rationale 4: Bladder irritation from chemotherapy would not cause renal failure. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Spinal cord compression does not cause renal failure. Urethral strictures from radiation would not cause renal failure. Bladder irritation from chemotherapy would not cause renal failure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Explain causes and discuss the nursing interventions for common oncologic emergencies. MNL Learning Outcome: 3.3.3. Critique interventions appropriate for the client with cancer. Page Number: 369
Question 37 Type: MCSA 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.” Correct Answer: 1 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The patient should call the nurse or physician if an oral temperature is greater than 101.5° F, not 100.5° F. Rationale 3: The physician or nurse does not need to be contacted if the patient experiences an episode of diarrhea. Rationale 4: The physician or nurse does not need to be contacted if the patient experiences an occasional headache. Global Rationale: 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. The physician or nurse does not need to be contacted if the patient experiences an episode of diarrhea or an occasional headache. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Evaluation Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 366
Question 38 Type: MCSA 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 anticipatory 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. The patient wants something to do while waiting for chemotherapy treatments. Correct Answer: 1 Rationale 1: Anticipatory grieving is a response to loss that has not yet occurred. 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. Rationale 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. Rationale 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. Rationale 4: The patient is not doing these activities while waiting for chemotherapy treatments. Global Rationale: Anticipatory grieving is a response to loss that has not yet occurred. 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. Participating in the activities of a will and funeral arrangements does not mean that the patient feels he is going to die within the month or that the patient’s family will not be willing to make funeral arrangements. The patient is not doing these activities while waiting for chemotherapy treatments. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 365
Question 39 Type: MCSA 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Encourage socialization with small children. 3. Contact physician with a temperature elevation. 4. Limit intake of protein and vitamin C. Correct Answer: 1 Rationale 1: The nurse should instruct the patient to avoid crowds and children to reduce the risk of developing an infection. Rationale 2: The nurse should instruct the patient to avoid socializing with children to reduce the risk of developing an infection. Rationale 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. Rationale 4: The patient should be instructed to have an adequate daily intake of protein and vitamin C to support the body’s immunity. Global Rationale: The nurse should instruct the patient to avoid crowds and children to reduce the risk of developing an infection. 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. The patient should be instructed to have an adequate daily intake of protein and vitamin C to support the body’s immunity. Cognitive Level: Applying Client Need: Safe and Effective Care Environment Client Need Sub: Safety and Infection Control 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: Implementation Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 365
Question 40 Type: MCMA 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 guidelines should the nurse instruct this family that indicates the patient needs medical intervention? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Standard Text: 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 Correct Answer: 2,3,5 Rationale 1: The patient should call the nurse or physician if the patient experiences an oral temperature greater than 101.5° F (38.6° C). Rationale 2: The patient should call the nurse or physician if the patient experiences difficulty breathing. Rationale 3: The patient should call the nurse or physician if the patient experiences a new onset of bleeding. Rationale 4: There is no reason to call the nurse or physician if the patient is resting comfortably and reading. Rationale 5: The patient should call the nurse or physician if the patient experiences extreme hunger. Global Rationale: The nurse should instruct the patient and family to call the physician or nurse for help with any of the following signs or symptoms: an oral temperature greater than 101.5° F (38.6°C); severe headache; significant increase in pain at usual site, especially if the pain is not relieved by the medication regimen; severe pain at a new site; difficulty breathing; new bleeding from any site, such as rectal or vaginal bleeding; confusion, irritability, or restlessness; withdrawal; greatly decreased activity level; frequent crying; verbalizations of deep sadness or a desire to end life; changes in body functioning, such as the inability to void or severe diarrhea or constipation; changes in eating patterns, such as refusal to eat, extreme hunger, or a significant increase in nausea and vomiting; and appearance of edema in the extremities or significant increase in edema already present. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Explain causes and discuss the nursing interventions for common oncologic emergencies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 366
Question 41 Type: MCHS Place an “X” at the site where a mediastinal or thoracic tumor causing superior vena cava syndrome is located.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: The superior vena cava can be compressed by mediastinal tumors or adjacent thoracic tumors. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe the physical and psychologic effects of cancer. MNL Learning Outcome: 3.2.1. Analyze the physiological and psychological aspects of cancer. Page Number: 368 Question 42 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCMA The nurse is caring for a patient diagnosed with a malignant neoplasm. What does the nurse recognize are characteristics of this neoplasm? Standard Text: 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 Correct Answer: 3, 4 Rationale 1: Benign neoplasms are localized growths. They form a solid mass, have well-defined borders, and frequently are encapsulated. Rationale 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). Rationale 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. Rationale 4: Instead of slowly crowding other tissues aside, malignant neoplasms cut through surrounding tissues, causing bleeding, inflammation, and necrosis (tissue death) as they grow. Rationale 5: They grow slowly and often remain stable in size. Global Rationale: Benign neoplasms are localized growths. They form a solid mass, have well-defined borders, and frequently are encapsulated. 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). They grow slowly and often remain stable in size. Because they are usually encapsulated, benign neoplasms often are easily removed and tend not to recur. 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. Instead of slowly crowding other tissues aside, malignant neoplasms cut through surrounding tissues, causing bleeding, inflammation, and necrosis (tissue death) as they grow. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare the mechanisms and characteristics of normal cells with malignant cells. MNL Learning Outcome: 3.1.2. Contrast normal cell function with that of cancer cells. Page Number: 341
Question 43 Type: MCSA The nurse is reviewing data collected on a group of patients being treated for cancer. Which patient or patients’ cancer type, pathophysiology, and symptoms should the nurse identify as being consistent with the oncological emergency of superior vena cava syndrome?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Patient C 2. Patient D 3. Patient A only 4. Patients A and B Correct Answer: 4 Rationale 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. Rationale 2: Signs and symptoms may develop slowly; facial, periorbital, and arm edema are early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits may occur. Rationale 3: 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. Occasionally the problem is caused by thrombus around a central venous catheter that then plugs up the vena cava, resulting in obstruction and backup of the blood flowing into the superior vena cava. Obstruction of the venous system causes increased venous pressure, venous stasis, and engorgement of veins that are drained by the superior vena cava. Signs and symptoms may develop slowly; facial, periorbital, and arm edema are early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits may occur. Rationale 4: 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. Occasionally the problem is caused by thrombus around a central venous catheter that then plugs up the vena cava, resulting in obstruction and backup of the blood flowing into the superior vena cava. Obstruction of the venous system causes increased venous pressure, venous stasis, and engorgement of veins that are drained by the superior vena cava. Signs and symptoms may develop slowly; facial, periorbital, and arm edema are early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits may occur. Global Rationale: 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. Occasionally the problem is caused by thrombus around a central venous catheter that then plugs up the vena cava, resulting in obstruction and backup of the blood flowing into the superior vena cava. Obstruction of the venous system causes increased venous pressure, venous stasis, and engorgement of veins that are drained by the superior vena cava. Signs and symptoms may develop slowly; facial, periorbital, and arm edema are early signs. As the problem progresses, respiratory distress, dyspnea, cyanosis, tachypnea, and altered consciousness and neurologic deficits may occur. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Evaluation Learning Outcome: 3. Describe the physical and psychologic effects of cancer. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 368
Question 44 Type: MCMA The nurse is reviewing the results of diagnostic testing on a patient suspected of having cancer. Which diagnostic findings should the nurse identify as being consistent with the presence of a malignancy? Standard Text: 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 Correct Answer: 1, 2 Rationale 1: High levels of tumor markers are indicative of a malignancy. Rationale 2: Positive biopsy results are indicative of a malignancy. Rationale 3: High levels of tumor markers are indicative of a malignancy. Rationale 4: Leukopenia is not associated with a malignancy. Rationale 5: Increased hemoglobin and hematocrit values are not associated with a malignancy. Global Rationale: High levels of tumor markers are indicative of a malignancy. Positive biopsy results are indicative of a malignancy. Leukopenia is not associated with a malignancy. Increased hemoglobin and hematocrit values are not associated with a malignancy. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Describe and compare laboratory and diagnostic tests for cancer. MNL Learning Outcome: 3.2.2. Distinguish tests used in the diagnosis of cancer. Page Number: 346-349
Question 45 Type: MCMA 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? Standard Text: 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. If needed use an electric razor for shaving. 5. Wear tight fighting clothing over the area to protect it. Correct Answer: 1, 4 Rationale 1: The site may be cleaned with soap and water. Rationale 2: Lotion should not be applied to the site. Rationale 3: Ice packs should not be applied to the site. Rationale 4: An electric razor may be used to shave the site. Rationale 5: Tight fitting clothing should not be worn over the site. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Options 2, 3, and 5 are contraindicated for this patient as they will increase the likelihood of tissue trauma at the radiation site. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.2.4. Examine other options for the treatment of cancer. Page Number: 359
Question 46 Type: MCMA A patient with cancer is diagnosed with malnutrition. What does the nurse realize are causes of malnutrition in this patient? Standard Text: Select all that apply. 1. decreases in metabolism resulting from increased cancer cell production 2. decreased available nutrients due to the cancers 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 Correct Answer: 2, 3, 4 Rationale 1: The patient’s metabolism will increase, not decrease. Rationale 2: The patient with cancer may have a decreased amount of available nutrients. Rationale 3: The patient may lose his or her appetite. Rationale 4: The patient may not be able to absorb the nutrients well from the gastrointestinal tract. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Parenteral nutrition is not a cause of malnutrition. It can be used to help the patient with cancer. Global Rationale: The patient with cancer may have a decreased amount of available nutrients. The patient may lose his or her appetite. The patient may not be able to absorb the nutrients well from the gastrointestinal tract. The patient’s metabolism will not decrease, it will increase. Parenteral nutrition is not a cause of malnutrition. It can be used to help the patient with cancer. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 366
Question 47 Type: MCMA The nurse realizes that a patient receiving chemotherapy for cancer is at risk for developing an infection. What actions should the nurse take when caring for this patient? Standard Text: 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. Correct Answer: 2, 3, 4 Rationale 1: Although RBCs are monitored, they do not diagnose infection as do WBCs.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 3: Appropriate skin care measures, such as the use of a moisturizing lotion to prevent dryness and cracking ensures intact skin. Rationale 4: Improving nutrition decreases the risk of infection. Vitamin C has been shown to help prevent certain types of infection, such as colds. Rationale 5: A temperature of 98° F is normal and does not need to be reported to the nurse or physician. Global Rationale: Although RBCs are monitored, they do not diagnose infection as do WBCs. 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. Teach appropriate skin care measures, such as the use of a moisturizing lotion to prevent dryness and cracking ensures intact skin. Improving nutrition decreases the risk of infection. Vitamin C has been shown to help prevent certain types of infection, such as colds. A temperature of 98° F is normal and does not need to be reported to the nurse or physician. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 365
Question 48 Type: MCMA 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? Standard Text: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 1, 2, 4, 5 Rationale 1: A diet that is high in red meat and saturated fat appears to increase the risk for cancer. Rationale 2: Both regular and decaffeinated coffee are believed to increase cancer risk. Rationale 3: Vegetables, fruits, fiber, folate, and calcium may be protective against cancer. Rationale 4: Repeatedly using fat to fry foods at high temperatures produces high levels of polycyclic hydrocarbons, which increase cancer risk considerably. Rationale 5: Some foods are considered genotoxic, such as the nitrosamines and nitrous indoles found in preserved meats and pickled, salted foods. Global Rationale: A diet that is high in red meat and saturated fat appears to increase the risk for cancer. Both regular and decaffeinated coffee are believed to increase cancer risk. Repeatedly using fat to fry foods at high temperatures produces high levels of polycyclic hydrocarbons, which increase cancer risk considerably. Some foods are considered genotoxic, such as the nitrosamines and nitrous indoles found in preserved meats and pickled, salted foods. Vegetables, fruits, fiber, folate, and calcium may be protective against cancer. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Evaluation Learning Outcome: 1. Explain known carcinogens, carcinogenesis, and identify risk factors for cancer. MNL Learning Outcome: 3.1.1. Classify the factors that increase the risk for developing cancer. Page Number: 336
Question 49 Type: MCMA After cytologic examination a patient is diagnosed with a tumor that is staged as TIS, N1a, M0. What does this staging classification indicate to the nurse about the patient’s tumor? Standard Text: 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
5. N1a means that no lymph nodes are involved. Correct Answer: 1, 3, 5 Rationale 1: TIS means that the tumor is in situ. Rationale 2: M0 means there is no evidence of distant metastasis. Rationale 3: M0 means there is no evidence of distant metastasis. Rationale 4: N1a means there is no metastasis to regional lymph nodes. Rationale 5: N1a means there is no metastasis to regional lymph nodes. Global Rationale: TIS means that the tumor is in situ. M0 means there is no evidence of distant metastasis. N1a means there is no metastasis to regional lymph nodes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Evaluation Learning Outcome: 4. Describe and compare laboratory and diagnostic tests for cancer. MNL Learning Outcome: 3.2.2. Distinguish tests used in the diagnosis of cancer. Page Number: 347
Question 50 Type: MCMA 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? Standard Text: Select all that apply. 1. Cisplatin 2. Prednisone 3. Methotrexate 4. Mercaptopurine 5. Nitrogen mustard Correct Answer: 1, 2, 5 Rationale 1: Cisplatin is a miscellaneous medication provided during the G1 phase of the cell cycle. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Prednisone is a hormone provided during the G1 phase of the cell cycle. Rationale 3: Methotrexate is an antimetabolite used during the S phase of the cell cycle. Rationale 4: Mercaptopurine is an antimetabolite used during the S phase of the cell cycle. Rationale 5: Nitrogen mustard is an alkylating agents prescribed during the G1 phase of the cell cycle Global Rationale: Cisplatin is a miscellaneous medication provided during the G1 phase of the cell cycle. Prednisone is a hormone provided during the G1 phase of the cell cycle. Nitrogen mustard is an alkylating agents prescribed during the G1 phase of the cell cycle. Methotrexate and mercaptopurine are antimetabolites used during the S phase of the cell cycle. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Discuss the role of chemotherapy in cancer treatment and classify chemotherapeutic agents. MNL Learning Outcome: 3.2.3. Compare chemotherapeutic options for the treatment of cancer. Page Number: 352
Question 51 Type: MCMA 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? Standard Text: 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 liters of fluid during treatment. Correct Answer: 1, 2, 5 Rationale 1: Adverse effects of cyclophosphamide (Cytoxan) include stomatitis. The patient should be instructed to avoid eating spicy foods. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Adverse effects of cyclophosphamide (Cytoxan) include alopecia. Approaches to managing hair loss should be discussed. Rationale 3: Bone pain is not an adverse effect of cyclophosphamide (Cytoxan). Rationale 4: Constipation is not an adverse effect of cyclophosphamide (Cytoxan). Rationale 5: Adverse effects of cyclophosphamide (Cytoxan) include hemorrhagic cystitis and renal failure. The nurse should instruct the patient to ingest 2 to 3 liters of fluid during treatment. Global Rationale: Adverse effects of cyclophosphamide (Cytoxan) include hemorrhagic cystitis, renal failure, alopecia, stomatitis, and liver dysfunction. The nurse should encourage a daily fluid intake of 2 to 3 liters during treatment and offer suggestions to manage hair loss. However, spicy foods are not recommended for patients with stomatitis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Discuss the role of chemotherapy in cancer treatment and classify chemotherapeutic agents. MNL Learning Outcome: 3.2.3. Compare chemotherapeutic options for the treatment of cancer. Page Number: 354, 365-366
Question 52 Type: MCMA A patient with a known drug allergy to Tetracycline is experiencing stomatitis from chemotherapy used to treat colon cancer. What combination mouthwashes for oropharyngeal pain control should the nurse suggest the healthcare provider prescribe for this patient? Standard Text: Select all that apply. 1. Kaiser 2. Stanford 3. Xyloxylin suspension 4. Stomafate suspension 5. Listerine antibacterial Correct Answer: 3, 4 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Kaiser mouthwash contains tetracycline. Rationale 2: Stanford mouthwash contains tetracycline. Rationale 3: Xyloxylin suspension does not contain tetracycline. Rationale 4: Stomafate suspension does not contain tetracycline. Rationale 5: Listerine antibacterial is not a recommended mouthwash for oropharyngeal pain control. Global Rationale: Xyloxylin suspension and Stomafate suspension do not contain tetracycline. Kaiser mouthwash and Stanford mouthwash both contains tetracycline. Listerine antibacterial is not a recommended mouthwash for oropharyngeal pain control. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 8. Design an appropriate care plan for patients with cancer and their families regarding cancer diagnosis, treatment, and coping strategies. MNL Learning Outcome: 3.3.4. Utilize the nursing process in care of client. Page Number: 368
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 15 Question 1 Type: MCSA A patient is experiencing a problem with the eccrine sweat glands. Because of this structural problem, the nurse realizes that which function will 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 Correct Answer: 2 Rationale 1: The dermis regulates body temperature by dilating and constricting capillaries. Rationale 2: The eccrine sweat glands regulate body heat by excreting perspiration. Rationale 3: Sebaceous (oil) glands secrete sebum, which lubricates the skin and hair and plays a role in killing bacteria. Rationale 4: The apocrine sweat glands are a remnant of sexual scent glands. Global Rationale: The dermis regulates body temperature by dilating and constricting capillaries. The eccrine sweat glands regulate body heat by excreting perspiration. Sebaceous (oil) glands secrete sebum, which lubricates the skin and hair and plays a role in killing bacteria. The apocrine sweat glands are a remnant of sexual scent glands. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the anatomy, physiology, and functions of the skin, hair, and nails. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 378 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 2 Type: MCSA During a conversation with the nurse, a patient comments that he rarely goes outside when the sun is shining because he is afraid of developing skin cancer. Which health problem is this patient at risk for developing? 1. vitamin D deficiency 2. hypercholesterolemia 3. hypokalemia 4. hypernatremia Correct Answer: 1 Rationale 1: The skin functions as a synthesizer of vitamin D (sunlight reacts with cholesterol). Rationale 2: Hypercholesterolemia results from factors such as dietary intake and cholesterol that is produced by the body. Rationale 3: The skin does retard 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. Rationale 4: The skin does retard 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. Global Rationale: The skin functions as a synthesizer of vitamin D (sunlight reacts with cholesterol). Hypercholesterolemia results from factors such as dietary intake and cholesterol that is produced by the body. The skin does retard 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 or hypernatremia. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the anatomy, physiology, and functions of the skin, hair, and nails. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 378
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 3 Type: MCMA A patient who has experienced a burn involving both the epidermis and the dermis asks if the area will heal and be as it was prior to the burn. What knowledge of skin structures should the nurse use to respond to this patient? Standard Text: Select all that apply. 1. Most hair follicles are in the dermis. 2. Most sweat glands are in the dermis. 3. Hair follicles are located in the subcutaneous tissue. 4. Sebaceous glands are located in the dermis. 5. Receptors for pain and touch are located in the dermis. Correct Answer: 1, 2, 4, 5 Rationale 1: Most hair follicles are located in the dermis. Rationale 2: Most sweat glands are located in the dermis. Rationale 3: Hair follicles are not located in the subcutaneous tissue. Rationale 4: Most sebaceous glands are located in the dermis. Rationale 5: The pain and touch receptors are located in the dermis. Global Rationale: Most sebaceous glands and sweat glands, as well as the pain and touch receptors, are located in the dermis. Most hair follicles are also located in the dermis, not the subcutaneous tissue. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the anatomy, physiology, and functions of the skin, hair, and nails. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 379
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 4 Type: MCSA The nurse is caring for an African American patient who has a serum bilirubin of 6 mg/100 mL. What is the best way of assessing skin color changes in this patient? 1. Assess the sclera. 2. Assess the palms of the hands. 3. Assess the fingernails. 4. Assess the skin of the inner arms. Correct Answer: 2 Rationale 1: Sclera may be yellow near the limbus; however, this can be confused with normal yellow eye pigmentation. Rationale 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. Rationale 3: Jaundice might be observed in the fingernails of a light-skinned patient. Rationale 4: Jaundice is not assessed by looking at the skin of the inner arms. Global Rationale: 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. Sclera may be yellow near the limbus; however, this can be confused with normal yellow eye pigmentation. Jaundice might be observed in the fingernails of a light-skinned patient. Jaundice is not assessed by looking at the skin of the inner arms. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Discuss factors that influence skin color. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 380 Question 5 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is caring for an African American patient who has an ashen cast to his normally black skin. Which laboratory test results should the nurse review to determine a possible cause of the skin color change? 1. BUN 2. hemoglobin and hematocrit 3. bilirubin 4. oxygen saturation Correct Answer: 2 Rationale 1: BUN levels are associated with kidney function; uremia may manifest as a yellowish green color in the sclera of the eye. Rationale 2: Decreased hemoglobin and hematocrit indicate anemia, which presents in black skin as dullness and an ashen gray cast. Rationale 3: An elevated bilirubin level is seen as yellowing of the skin, especially evident in the palms of darkskinned individuals. Rationale 4: Decreased oxygen saturation or low arterial blood gas levels present as cyanosis or a bluish discoloration in nail beds in dark-skinned individuals. Global Rationale: Decreased hemoglobin and hematocrit indicate anemia, which presents in black skin as dullness and an ashen gray cast. BUN levels are associated with kidney function; uremia may manifest as a yellowish green color in the sclera of the eye. An elevated bilirubin level is seen as yellowing of the skin especially evident in the palms of dark-skinned individuals. Decreased oxygen saturation presents as cyanosis or a bluish discoloration in nail beds in dark-skinned individuals. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Discuss factors that influence skin color. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 380 Question 6 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A Caucasian patient is admitted with possible carbon monoxide poisoning. What skin color can the nurse expect to find that would support this diagnosis? 1. bluish 2. dusky red 3. cherry red 4. orange green Correct Answer: 3 Rationale 1: Bluish skin is associated with cyanosis. Rationale 2: Dusky red skin is found in individuals with venous stasis. Rationale 3: Carbon monoxide poisoning is characterized by cherry red coloring of the face and upper torso. Rationale 4: Dusky red skin is found in individuals with venous stasis and orange green skin in found in individuals with uremia. Global Rationale: Carbon monoxide poisoning is characterized by cherry red coloring of the face and upper torso. Bluish skin is associated with cyanosis. Dusky red skin is found in individuals with venous stasis, and orange green skin in individuals with uremia. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Discuss factors that influence skin color. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 380
Question 7 Type: MCSA While conducting a patient’s health history, the nurse learns that the patient has worked at a landfill for the last 35 years. Why should the nurse find this information significant?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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 Correct Answer: 1 Rationale 1: The patient’s occupation could involve exposure to such toxins as arsenic, coal, tar, creosote, and/or petroleum products. Working at a landfill is a risk factor for skin cancer. Rationale 2: Working at a landfill has no bearing on the patient’s communication skills. Rationale 3: Working at a landfill has nothing to do with the patient’s age. Rationale 4: Working at a landfill has no bearing on the patient’s education level. Global Rationale: The patient’s occupation could involve exposure to such toxins as arsenic, coal, tar, creosote, and/or petroleum products. Working at a landfill is a risk factor for skin cancer. It has no bearing on a patient’s communication skills, age, or education level. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Identify specific topics for a health history interview of the patient with problems involving the skin, hair, or nails. MNL Learning Outcome: 4.4.4. Plan the care of a client with a hair or nail disorder. Page Number: 382 Question 8 Type: MCMA A patient is seen for an erythematous generalized rash. Which questions should the nurse ask regarding the rash? Standard Text: Select all that apply. 1. “Have you recently eaten any new foods?” 2. “What medications do you take?” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. “Have you changed your soap?” 4. “Have you changed skin care lotions?” 5. “How often do you walk outside?” Correct Answer: 1,2,3,4 Rationale 1: When assessing a patient with a new rash, the nurse should about precipitating factors such as dietary changes. Rationale 2: When assessing a patient with a new rash, the nurse should about precipitating factors such as medications. Rationale 3: When assessing a patient with a new rash, the nurse should about precipitating factors such as changes in soap. Rationale 4: When assessing a patient with a new rash, the nurse should about precipitating factors such as changes in skin care lotion. Rationale 5: Asking whether the patient walks outside will not help the nurse identify the cause of the rash. Global Rationale: When assessing a patient with a new rash, the nurse should about precipitating factors such as medications, the use of new soaps and skin care products, and dietary changes. Asking whether the patient walks outside will not help the nurse identify the cause of the rash. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Identify specific topics for a health history interview of the patient with problems involving the skin, hair, or nails. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 381-382 Question 9 Type: MCSA A patient being seen for an elevated, darkened area of excess scar tissue asks the nurse what caused it. How should the nurse respond? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 2 Rationale 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. Rationale 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. Rationale 3: An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. Rationale 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. Global Rationale: 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. 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. An ulcer is a deep, irregularly shaped area of skin loss extending into the dermis or subcutaneous tissue. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 381-382 Question 10 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is performing an assessment of a patient’s nails. What should be included in this examination? Standard Text: Select all that apply. 1. nail thickness 2. nail color 3. nail curvature 4. nail length 5. for grooves Correct Answer: 1, 2, 3, 5 Rationale 1: Nails should be inspected for thickness. Rationale 2: Nails should be inspected for color. Rationale 3: Nails should be inspected for curvature. Rationale 4: Nail length is not an important assessment. Rationale 5: Nails should be inspected for grooves. Global Rationale: Nails should be inspected for color and thickness. Also, the surface of the nail should be inspected for grooves and curvature. Nail length is not an important assessment. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 385-386 Question 11 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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? Standard Text: 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 Correct Answer: 1, 2, 3 Rationale 1: A health assessment interview to determine problems with the integumentary system may focus on a chief complaint (such as itching or a rash). Rationale 2: A health assessment interview to determine problems with the integumentary system may be conducted as part of a health screening. Rationale 3: A health assessment interview to determine problems with the integumentary system may be conducted as part of a complete health assessment. Rationale 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. Rationale 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. Global Rationale: A health assessment interview to determine problems with the integumentary system may be conducted as part of a health screening or complete health assessment, or it may focus on a chief complaint (such as itching or a rash). It is to be completed regardless of the amount of time it takes to complete. It is also conducted on patients of all ages, not just those over the age of 50. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 381 Question 12 Type: MCSA The nurse is caring for a patient 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 Correct Answer: 1 Rationale 1: Oculocutaneous albinism is an autosomal-recessive disorder that causes hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin. Rationale 2: Keloids are elevated scars, have a familial tendency, and are found more commonly in African Americans. Rationale 3: Vitiligo is the sudden appearance of white patches on the skin; it has a familial tendency. Rationale 4: Oculocutaneous albinism is an autosomal-recessive disorder that causes hypopigmentation of the skin, hair, and eyes. Global Rationale: Oculocutaneous albinism is an autosomal-recessive disorder that causes hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin. Vitiligo is the sudden appearance of white patches on the skin; it has a familial tendency. Keloids are elevated scars, have a familial tendency, and are found more commonly in African Americans. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Give examples of genetic disorders of the integumentary system. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 381 Question 13 Type: MCSA A female patient who is concerned about excessive hair on her arms and legs states that her mother had 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.” Correct Answer: 2 Rationale 1: Diet is not known to increase arm and hair growth. Rationale 2: Hirsutism, or excessive hair growth, may be genetically predetermined. Rationale 3: Hirsutism is not caused by too much sun. Rationale 4: Hirsutism is not caused by excessive shaving. Global Rationale: Hirsutism, or excessive hair growth, may be genetically predetermined. It is not known to be caused by diet, sun exposure, or shaving. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Give examples of genetic disorders of the integumentary system. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 381 Question 14 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient complains of the sudden appearance of white patches on the skin. The nurse, suspecting vitiligo, should ask the patient which questions? Standard Text: 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?” Correct Answer: 1, 5 Rationale 1: Vitiligo has a familial tendency. Rationale 2: Vitiligo is not caused by chemical exposure. Rationale 3: Vitiligo is not caused by irritation. Rationale 4: Vitiligo is not caused by dietary factors. Rationale 5: Vitiligo usually occurs on the face, the hands, or the groin. Global Rationale: Vitiligo usually occurs in individuals as a result of a familial tendency. It usually occurs on the face, hands, or groin. It is not caused by irritation, chemicals, or dietary factors. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Give examples of genetic disorders of the integumentary system. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 381, 384 Question 15 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is completing an integumentary examination with an African American patient. Which findings should the nurse recognize are associated with the patient’s genetics? Standard Text: 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 Correct Answer: 3, 4, 5 Rationale 1: An ashen hue to the skin is a sign of anemia. Rationale 2: A yellowish cast to the skin of the palms may indicate jaundice. Rationale 3: Dry scalp and dry, fragile hair may have a genetic origin in African American individuals. Rationale 4: Keloids occur in African American individuals with a familial tendency. Rationale 5: White patches, or vitiligo, often found over the skin of the face, hands, or groin, occur in individuals with a familial tendency. Global Rationale: Dry scalp and dry, fragile hair may have a genetic origin in African American individuals. Keloids also occur in African American individuals with a familial tendency. An ashen hue to the skin is a sign of anemia. A yellowish cast to the skin noticed on the palms may indicate jaundice. White patches, or vitiligo, often found over the skin of the face, hands, or groin, occur in individuals with a familial tendency. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Give examples of genetic disorders of the integumentary system. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 380-381, 384 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 16 Type: MCSA 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. Correct Answer: 1 Rationale 1: The subcutaneous layer thins, leading to a greater risk of hypothermia and pressure ulcers. Rationale 2: The thickness of the epidermis decreases, making the skin more fragile and increasing the risk of tears and injury. Rationale 3: The number of Langerhans cells decreases, making the older patient more susceptible to infection. Rationale 4: Sweat gland activity decreases, resulting in drier skin and decreased perspiration. Global Rationale: The subcutaneous tissue layer thins, leading to a greater risk of hypothermia and pressure ulcers. Sweat gland activity decreases, resulting in drier skin and decreased perspiration. The thickness of the epidermis decreases, making the skin more fragile and increasing the risk of tears and injury. The number of Langerhans cells decreases, making the older patient more susceptible to infection. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.8. 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: Implementation Learning Outcome: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 383 Question 17 Type: MCSA When conducting a physical examination of the skin, hair, and nails, the nurse notes the age of the patient. Why is this information important to the nurse? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 1: The nurse should expect findings related to the aging process. Rationale 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. Rationale 3: Scaly, dry skin is not common in young adults. Rationale 4: Age is not the most significant risk factor for cancer. Global Rationale: The nurse should expect findings related to the aging process. 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. Age is not the most significant risk factor for cancer. Scaly, dry skin is not common in young adults. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 383 Question 18 Type: MCSA The nurse is assessing the integumentary status of an older patient. What change should the nurse expect in this patient? 1. a decrease in abdominal fat 2. an increase in perfusion LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. a decrease in vitamin D production 4. an increase in vasomotor response Correct Answer: 3 Rationale 1: In older adults, there is an increase in abdominal fat due to the redistribution of adipose tissue. Rationale 2: Perfusion of the dermis decreases in older adults. Rationale 3: Vitamin D production in the epidermis declines in older adults. Rationale 4: The vasomotor response of the dermis declines in older adults. Global Rationale: In older adults there is an increase in abdominal fat due to the redistribution of adipose tissue. Vitamin D production in the epidermis, as well as vasomotor response and perfusion of the dermis, all decline in older adults. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 383 Question 19 Type: MCSA 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. a telangiectases Correct Answer: 3 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Keratoses are the horny growths of keratinocytes. Rationale 2: Angiomas are benign vascular tumors with dilated blood vessels found in the middle to upper dermis. Rationale 3: Lentigines, or liver spots, are brown or black benign macules with a defined border. Rationale 4: Telangiectases are single dilated blood vessels, capillaries, or terminal arteries. Global Rationale: Keratoses are the horny growths of keratinocytes. Angiomas are benign vascular tumors with dilated blood vessels found in the middle to upper dermis. Lentigines, or liver spots, are brown or black benign macules with a defined border. Telangiectases are single dilated blood vessels, capillaries, or terminal arteries. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 382 Question 20 Type: MCSA 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 Correct Answer: 1 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 4: Scales are shedding flakes of greasy, keratinized skin tissue. Examples of scales include dry skin, dandruff, psoriasis, and eczema. Global Rationale: 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. 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. 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. Scales are shedding flakes of greasy, keratinized skin tissue. Examples of scales include dry skin, dandruff, psoriasis, and eczema. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 382 Question 21 Type: MCSA The nurse is assessing a patient with the following laboratory values: sodium 144 mEq/L; potassium 3.8 mEq/L; hemoglobin 8.4 g/dL; glucose 105 mg/dL. Which assessment might correlate with these findings? 1. The nail plate is separate from the nail bed. 2. The nail folds are inflamed and swollen. 3. The nail is spoon-shaped. 4. The nail has a transverse groove. Correct Answer: 3 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 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. Rationale 4: Nail grooves may be caused by inflammation, planus, or nail biting. This patient’s laboratory values do not suggest any of these. Global Rationale: 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. The other assessments would not correlate with these laboratory values. The nail plate may separate from the nail bed in trauma, psoriasis, and Pseudomonas and Candida infections. Nail grooves may be caused by inflammation, planus, or nail biting. The nail folds become inflamed and swollen and the nail loosens in paronychia, an infection of the nails. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.1.4. Plan the care of a client with a hair or nail disorder. Page Number: 385-386 Question 22 Type: MCSA A patient diagnosed with heart failure has 3+ lower extremity edema. Which description most accurately describes this patient’s edema? 1. slight pitting, no obvious distortion 2. deeper pit, no obvious distortion 3. pit is obvious, extremities are swollen LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. pit remains with obvious distortion Correct Answer: 3 Rationale 1: 1+ edema is slight pitting with no obvious distortion. Rationale 2: 2+ edema is a deeper pit, but there is no obvious distortion. Rationale 3: In 3+ edema, the pit is obvious, and the extremities are swollen. Rationale 4: In 4+ edema, the pit remains, with obvious distortion. Global Rationale: Edema is the accumulation of fluid in the body’s tissues. It can be assessed by depressing the patient’s skin. 1+ edema is slight pitting with no obvious distortion. 2+ edema is a deeper pit, but there is no obvious distortion. In 3+ edema, the pit is obvious, and the extremities are swollen. In 4+ edema, the pit remains, with obvious distortion. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 6.8.2. Differentiate the manifestations and diagnosis of pump failure. Page Number: 385 Question 23 Type: MCSA 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 Correct Answer: 3
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Pulse oximetry measures the oxygen level of the blood. Decreased oxygenation might cause nail thickening. Rationale 2: Hemoglobin measures red blood cell oxygen-carrying capacity. If the patient has a hemoglobin problem, the nails would be spoon-shaped. Rationale 3: One laboratory test that assesses for nutritional deficiencies is a serum albumin level. This test would help explain thin nails. Rationale 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. Global Rationale: Thinning of the nails in seen in nutritional deficiencies. One laboratory test to assess for nutritional deficiencies is a serum albumin level. Pulse oximetry measures the oxygen level of the blood. Decreased oxygenation might cause nail thickening. Hemoglobin measures red blood cell oxygen-carrying capacity. If the patient has a hemoglobin problem, the nails would be spoon-shaped. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.4.2. Compare the manifestations of hair and nail disorders. Page Number: 386 Question 24 Type: MCHS Place an “X” over the structure whose decreased activity in older patients causes dry skin or absence of perspiration.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: The eccrine sweat gland produces sweat. The activity of these glands decreases with age, resulting in dry skin or absence of perspiration in older patients. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the anatomy, physiology, and functions of the skin, hair, and nails. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 378, 383 Question 25 Type: MCHS The nurse is caring for a patient with a skin fissure. Place an “X” over the diagram that represents a skin fissure.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer:
Rationale: A fissure is a linear crack with sharp edges extending into the dermis. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 387 Question 26 Type: MCHS A patient has a history of paronychia. Place an “X” on the area of the fingernail that becomes inflamed in paronychia.
Correct Answer: Rationale: Paronychia is an infection of the nails in which the nail folds become inflamed and the nail loosens. Global Rationale: Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 381 Question 27 Type: MCHS The nurse is assessing a patient for nail clubbing. Place an “X” on the area of the fingernail that the nurse should examine.
Correct Answer: Rationale: Clubbing has occurred when the angle of the nail base is greater than 180 degrees. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 385 Question 28 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse notes the presence of this lesion on the patient’s anterior chest. How should the nurse document this finding in the medical record?
1. purpura 2. ecchymosis 3. venous star 4. spider angioma Correct Answer: 3 Rationale 1: Purpura are flat, reddish blue, irregularly shaped, extensive patches of varying size. Rationale 2: Ecchymoses are flat, nonblanchable areas resulting from release of blood into superficial tissues. Rationale 3: This is a venous star, which is a flat blue lesion with radiating, cascading, or linear veins extending from the center. It ranges in size from 3 to 25 cm. Rationale 4: Spider angiomas are a form of telangiectasis that are bright red dots with tiny radiating blood vessels, ranging in size from a pinpoint to 2 cm. Global Rationale: This is a venous star, which is a flat blue lesion with radiating, cascading, or linear veins extending from the center. It ranges in size from 3 to 25 cm. Purpura are flat, reddish blue, irregularly shaped, extensive patches of varying size. Ecchymoses are flat, nonblanchable areas resulting from release of blood into
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
superficial tissues. Spider angiomas are a form of telangiectasis that are bright red dots with tiny radiating blood vessels, ranging in size from a pinpoint to 2 cm. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 388 Question 29 Type: MCSA The nurse notes this distribution of lesions on a patient’s skin. Based on this finding, the nurse should perform additional assessment looking for indications of which problem?
1. vitamin B deficiency 2. increased intravenous pressure 3. bleeding disorders LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. psoriasis Correct Answer: 3 Rationale 1: Vitamin B deficiency may cause spider angiomas to form. Rationale 2: Increased intravenous pressure is associated with the development of venous stars. Rationale 3: This is a picture of purpura, which are caused by bleeding disorders, scurvy, and capillary fragility. Rationale 4: Psoriasis causes scaly red patches, generally on the scalp, knees, back, and genitals. Global Rationale: This is a picture of purpura, which are caused by bleeding disorders, scurvy, and capillary fragility. Vitamin B deficiency may cause spider angiomas to form. Increased intravenous pressure is associated with the development of venous stars. Psoriasis causes scaly red patches, generally on the scalp, knees, back, and genitals. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 388 Question 30 Type: MCSA The nurse is assessing a patient’s skin. For what is the nurse assessing when using the technique shown in this picture?
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. hydration status 2. skin temperature 3. skin color 4. liver function Correct Answer: 1 Rationale 1: The nurse in this picture is assessing for “tenting” of the skin, which is an indication of hydration status. Rationale 2: Skin temperature is assessed using the back of the assessor’s hand. Rationale 3: Skin color is a visual inspection. Rationale 4: This action does not assess liver function. Global Rationale: The nurse in this picture is assessing for “tenting” of the skin, which is an indication of hydration status. Skin temperature is assessed using the back of the assessor’s hand. Skin color is a visual inspection. This action does not assess liver function. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 384 Question 31 Type: MCSA The nurse documents that a patient has 4+ pitting edema on the lower right tibia. How many millimeters of depression did this patient demonstrate? 1. 2 mm 2. 4 mm 3. 6 mm 4. 8 mm Correct Answer: 4 Rationale 1: +1 pitting edema is 2 mm of depression. Rationale 2: +2 pitting edema is 4 mm of depression. Rationale 3: +3 pitting edema is 6 mm of depression. Rationale 4: +4 pitting edema is 8 mm of depression. Global Rationale: +1 pitting edema is 2 mm of depression. +2 pitting edema is 4 mm. +3 pitting edema is 6 mm. +4 pitting edema is 8 mm. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 385 Question 32 Type: MCSA The nurse has assessed a flat, nonpalpable change in the skin color on a patient’s back. What characteristic identifies 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. Correct Answer: 1 Rationale 1: Macules are smaller than 1 cm, with a circumscribed border. Rationale 2: Patches are larger than 1 cm and may have irregular borders. Rationale 3: Papules are smaller than 0.5 cm. Rationale 4: Plaques are groups of papules that form lesions larger than 0.5 cm. Global Rationale: Macules are smaller than 1 cm, with a circumscribed border. Patches are larger than 1 cm and may have irregular borders. Papules are smaller than 0.5 cm. Plaques are groups of papules that form lesions larger than 0.5 cm. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 386 Question 33 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The patient states, “This dark spot on my arm is getting bigger, and it bleeds occasionally.” Which health information is most important relative to this report? Standard Text: 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. Correct Answer: 2, 3, 5 Rationale 1: A family history of COPD is not a risk factor for skin cancer. Rationale 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. Rationale 3: A dark spot on the arm that tends to bleed may be skin cancer. Risk factors for skin cancer include being male. Rationale 4: A family history of cardiac disease is not a risk factor for skin cancer. Rationale 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. Global Rationale: A dark spot on the arm that tends to bleed may be skin cancer. Risk factors for skin cancer include being male, extended exposure to sunlight, and having light-colored hair and eyes. A family history of COPD or cardiac disease is not a risk factor for skin cancer and would likely not manifest as a dark spot on the arm that is growing and tends to bleed. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Identify specific topics for a health history interview of the patient with problems involving the skin, hair, or nails. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 382 Question 34 Type: MCSA The nurse is preparing to conduct the health history of a new clinic patient. The intake notes reveal that the patient has albinism. What assessment finding should the nurse expect in this patient? 1. excessive body hair 2. white patches on the skin 3. overgrowth of scar tissue 4. very pale skin Correct Answer: 4 Rationale 1: Excessive body hair is hirsutism. Rationale 2: White patches on the skin are vitiligo. Rationale 3: Overgrowth of scar tissue forms keloids. Rationale 4: Albinism is an autosomal recessive condition causing hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin. Global Rationale: Albinism is an autosomal recessive condition causing hypopigmentation of the skin, hair, and eyes as a result of an inability to synthesize melanin. White patches on the skin are vitiligo. Excessive body hair is hirsutism. Overgrowth of scar tissue forms keloids. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 5. Give examples of genetic disorders of the integumentary system. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 381
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 35 Type: MCSA An adolescent patient has extensive acne over the face and upper neck. The nurse recognizes that this condition is caused by which factor? 1. inflamed sebaceous glands 2. blocked endocrine glands 3. blocked exocrine glands 4. inflamed ceruminous glands Correct Answer: 1 Rationale 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. Rationale 2: Acne is not caused by blocked endocrine glands. Rationale 3: Acne is not caused by blocked exocrine glands. Rationale 4: Acne is not caused by inflamed ceruminous glands. Global Rationale: 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. Acne is not caused by blocked endocrine, exocrine, or ceruminous glands. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 378, 384 Question 36 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.” Correct Answer: 4 Rationale 1: Answering the patient’s inquiry with a question is not therapeutic. Rationale 2: The nurse should not discourage the patient from obtaining treatments ordered. Rationale 3: The nurse needs to find out what occurs during the biopsy. This statement is not sufficient communication. Rationale 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. Global Rationale: 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. Answering the patient’s inquiry with a question is not therapeutic. The nurse should not discourage the patient from obtaining treatments ordered. The nurse needs to find out what occurs during the biopsy. This statement is not sufficient communication. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Implementation Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 381 Question 37 Type: MCSA The nurse is preparing to assess a patient’s integumentary status. Which techniques should the nurse use to conduct this assessment? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. inspection 2. inspection and percussion 3. inspection and palpation 4. percussion and palpation Correct Answer: 3 Rationale 1: Physical assessment of the skin, hair, and nails is conducted by inspection and another technique. Rationale 2: Physical assessment of the skin, hair, and nails is not done by percussion. Rationale 3: Physical assessment of the skin, hair, and nails is conducted by inspection and palpation. Rationale 4: Physical assessment of the skin, hair, and nails is not done by percussion. Global Rationale: Physical assessment of the skin, hair, and nails is conducted by inspection and palpation. Percussion employs tapping to assess structures beneath the skin’s surface. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 382 Question 38 Type: MCSA 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
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. pitting remains with obvious distortion Correct Answer: 1 Rationale 1: The designation +1 means that the patient has slight pitting in the right lower leg with no obvious distortion. Rationale 2: The designation +2 means that the patient has deep pitting in the right lower leg with no obvious distortion. Rationale 3: The designation +3 means that pitting is obvious, with swollen extremities. Rationale 4: The designation +4 means pitting remains with obvious distortion. Global Rationale: The designation +1 means that the patient has slight pitting in the right lower leg with no obvious distortion. The designation + 2 means that the patient has slight deep pitting in the right lower leg with no obvious distortion. The designation + 3 means that pitting is obvious, with swollen extremities. The designation + 4 means pitting remains with obvious distortion. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 385 Question 39 Type: MCMA The nurse is assessing the integumentary status of a 79-year-old female. Which findings should the nurse considered common in older adults? Standard Text: Select all that apply. 1. keratoses 2. skin tags 3. urticaria
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. photoaging 5. acne Correct Answer: 1, 2, 4 Rationale 1: Common skin lesions in older adults include keratoses. Rationale 2: Common skin lesions in older adults include skin tags. Rationale 3: Urticaria (hives) is an integumentary disorder that is not a normal sign of aging. Rationale 4: Common skin lesions in older adults include photoaging. Rationale 5: Acne is common in adolescents, not in older adults. Global Rationale: Common skin lesions in older adults include skin tags, keratoses, and photoaging. Urticaria (hives) is an integumentary disorder that is not normal. Acne is common in adolescents, not in older adults. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 382 Question 40 Type: MCSA The nurse is planning to assess an African American patient’s integumentary status. Which finding indicates the presence of cyanosis in this patient? 1. yellow hue in the eyes 2. bluish-tinged nail beds 3. cherry-red lips 4. orange-green cast to the skin
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2 Rationale 1: A yellowish hue indicates the presence of jaundice. Rationale 2: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae. Rationale 3: Cherry-red lips are associated with carbon monoxide poisoning. Rationale 4: An orange-green cast to the skin is not associated with any specific disorder. Global Rationale: Cyanosis is more readily assessed in the nail beds, oral mucous membranes, and conjunctivae. A yellowish hue indicates the presence of jaundice. Cherry-red lips are associated with carbon monoxide poisoning. An orange-green cast to the skin is not associated with any specific disorder. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Discuss factors that influence skin color. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 380 Question 41 Type: MCSA The nurse is planning to document the appearance of herpetic lesions found over a patient’s nose and mouth region. Which term should the nurse use to describe this finding? 1. scaly 2. pustular 3. pruritic 4. ulcerated Correct Answer: 4 Rationale 1: Scaly lesions are characteristic of eczema. Rationale 2: Pustular lesions are associated with acne. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Pruritic refers to itching. Rationale 4: Ulcerated is used to describe pressure ulcers, skin cancer, and herpes simplex. Global Rationale: Ulcerated is used to describe pressure ulcers, skin cancer, and herpes simplex. Scaly lesions are characteristic of eczema. Pustular lesions are associated with acne. Pruritic refers to itching. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 384, 387 Question 42 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Alterations in vitamin D production are not associated with excessive pigmentation. Rationale 3: Reduced blood perfusion is not associated with excessive pigmentation. Rationale 4: Changes in adipose tissue are not associated with excessive pigmentation.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Alterations in vitamin D production, reduced blood perfusion, and changes in adipose tissue are not associated with excessive pigmentation. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 382-383 Question 43 Type: MCSA A patient is seen in the clinic after having 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 Correct Answer: 2 Rationale 1: The incisional biopsy involves the removal of a portion of a tumor or lesion. Rationale 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. Rationale 3: The excisional biopsy is the removal of an entire lesion or tumor. Rationale 4: The shave biopsy is the scraping of a layer of cells for analyzing. Global Rationale: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
specimen for analyzing. The incisional biopsy involves the removal of a portion of a tumor or lesion. The excisional biopsy is the removal of an entire lesion or tumor. The shave biopsy is the scraping of a layer of cells for analyzing. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 382 Question 44 Type: MCSA 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 Correct Answer: 2 Rationale 1: Patch testing is used to assess allergens. Rationale 2: The Tzanck smear is used to diagnose herpes infections. Rationale 3: The potassium chloride test is used to diagnose interstitial cystitis. Rationale 4: The Wood’s lamp test is used to assess for tinea infections. Global Rationale: The Tzanck smear is used to diagnose herpes infections. Patch testing is used to assess allergens. The Wood’s lamp test is used to assess for tinea infections. The potassium chloride test is used to diagnose interstitial cystitis. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 382 Question 45 Type: MCMA The nurse is preparing to assess a patient’s integumentary status. What should the nurse do prior to beginning this examination? Standard Text: 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 Correct Answer: 1, 3, 4, 5 Rationale 1: For the examination the patient will remove all clothing and put on a gown or drape. Rationale 2: A blood pressure cuff is not used for this examination. Rationale 3: Disposable gloves are worn when palpating lesions, skin surfaces with infections or infestations, or discharge from skin lesions and mucous membranes. Rationale 4: The examination should be conducted in a warm, private room. Rationale 5: A ruler is used to measure the size of lesions. A flashlight is used to better visualize lesions. Global Rationale: For the examination the patient will remove all clothing and put on a gown or drape. Disposable gloves are worn when palpating lesions, skin surfaces with infections or infestations, or discharge from skin lesions and mucous membranes. The examination should be conducted in a warm, private room. A ruler is used to measure the size of lesions. A flashlight is used to better visualize lesions. A blood pressure cuff is not used for this examination. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 4. Explain techniques for assessing the skin, hair, and nails. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 383 Question 46 Type: MCMA The nurse is caring for an older patient with thin subcutaneous tissue. What actions should the nurse take to ensure the patient’s comfort and safety? Standard Text: 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 Correct Answer: 1, 3, 4, 5 Rationale 1: The older patient with thin subcutaneous tissue is at risk for hypothermia. Applying warm blankets will reduce this risk. Rationale 2: The older patient with thin subcutaneous tissue is at risk for hypothermia. The room should be warm, not cool. Rationale 3: Using a lift sheet to reposition in bed will reduce the risk of skin tears because of the flattened dermal–epidermal junction. Rationale 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. Rationale 5: The older patient with thin subcutaneous tissue is at risk for pressure ulcer formation. Frequent position changes will reduce this risk. Global Rationale: The older patient with thin subcutaneous tissue is at risk for hypothermia. Applying warm blankets will reduce this risk. The room should be warm, not cool. This patient is also at risk for pressure ulcer formation. Assessing the skin for areas of breakdown and frequent position changes will reduce this risk. Using a lift sheet to reposition in bed will reduce the risk of skin tears because of the flattened dermal–epidermal junction. Cognitive Level: Applying Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 6. Differentiate normal variations in assessment findings for the older adult. MNL Learning Outcome: 4.3.4. Utilize the nursing process in care of client. Page Number: 383 Question 47 Type: MCMA During an integumentary assessment the nurse observes multiple areas of ecchymosis over the patient’s arms, legs, and upper back. What problems should the nurse consider as causes of these manifestations? Standard Text: Select all that apply. 1. Septicemia 2. Hemophilia 3. Liver disease 4. Vitamin C deficiency 5. Vitamin K deficiency Correct Answer: 2, 3, 4, 5 Rationale 1: Petechiae can be caused by septicemia. Rationale 2: Ecchymosis can be caused by hemophilia. Rationale 3: Ecchymosis can be caused by liver disease. Rationale 4: Ecchymosis can be caused by Vitamin C deficiency. Rationale 5: Ecchymosis can be caused by Vitamin K deficiency. Global Rationale: Ecchymosis can be caused by hemophilia, liver disease, and vitamin C or K deficiency. Petechiae can be caused by septicemia. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.2. Differentiate the manifestations of non-malignant and malignant skin disorders. Page Number: 388 Question 48 Type: MCMA The nurse suspects that a school-age child has ringworm of the scalp. What did the nurse assess to come to this conclusion? Standard Text: 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 Correct Answer: 2, 3, 4 Rationale 1: Coarse, dry hair is associated with hypothyroidism. Rationale 2: Hair loss is associated with tinea capitis or scalp ringworm. Rationale 3: Scales on the scalp are associated with tinea capitis or scalp ringworm. Rationale 4: Pustules on the scalp are associated with tinea capitis or scalp ringworm. Rationale 5: Oval nits on the hair shaft are associated with head lice. Global Rationale: Hair loss, scales on the scalp, and pustules on the scalp are associated with tinea capitis, or scalp ringworm. Coarse, dry hair is associated with hypothyroidism. Oval nits on the hair shaft are associated with head lice. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.2. Differentiate the manifestations of non-malignant and malignant skin disorders. Page Number: 385 Question 49 Type: MCMA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Prior to assessing a patient’s integumentary status, the nurse notes excessive perspiration. What possible causes should the nurse consider for this finding? Standard Text: 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. Correct Answer: 2, 3, 4, 5 Rationale 1: Excessive perspiration is not associated with hunger. Rationale 2: Excessive perspiration may be associated with anxiety. Rationale 3: Excessive perspiration may be associated with shock. Rationale 4: Excessive perspiration may be associated with fever. Rationale 5: Excessive perspiration may be associated with increased activity. Global Rationale: Excessive perspiration may be associated with anxiety, shock, fever, or increased activity. Excessive perspiration is not associated with hunger. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate impairment of the integumentary system. MNL Learning Outcome: 4.2.2. Differentiate the manifestations of non-malignant and malignant skin disorders. Page Number: 384
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff, Medical-Surgical Nursing 6th Edition Test Bank Chapter 16 Question 1 Type: MCSA The mother of a teenage girl voices concerns about her daughter’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?” Correct Answer: 1 Rationale 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. Rationale 2: Dietary intake is not the primary cause of acne. Rationale 3: It would be premature to address the potential for the mother to be embarrassed about her daughter’s condition. Rationale 4: Hygiene is not the primary cause of acne. Global Rationale: 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. Dietary intake and hygiene are not the primary causes of acne. Acne is caused by excess sebum production. It would be premature to address the potential for the mother to be embarrassed about her daughter’s condition. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: 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; Practice; conduct population-based transcultural health assessments and interventions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the manifestations, self-care, and nursing care of common skin problems and lesions. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 408
Question 2 Type: MCSA A patient has a lesion in the left axilla that is deep, painful, and contains pus. It is 3 centimeters in diameter. After the assessment, what type of lesion should the nurse determine that the patient has? 1. furuncle 2. folliculitis 3. carbuncle 4. herpes varicella Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: A carbuncle is a group of infected hair follicles that interconnect. It is about 3 to 10 centimeters in diameter. Rationale 4: Herpes varicella (chickenpox) lesions are superficial and usually limited to the face, scalp, and chest. Global Rationale: 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. 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. A carbuncle is a group of infected hair follicles that interconnect. It is about 3 to 10 centimeters in diameter. Herpes varicella (chickenpox) lesions are superficial and usually limited to the face, scalp, and chest. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the manifestations, self-care, and nursing care of common skin problems and lesions. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 397
Question 3 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: There is no evidence that daily shaving will reduce folliculitis. Rationale 3: There is no evidence that shaving closely will reduce folliculitis. Rationale 4: There is no evidence that shaving in the opposite direction of hair growth will reduce folliculitis. Global Rationale: 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. There is no evidence that daily shaving will reduce folliculitis. There is no evidence that shaving closely will reduce folliculitis. There is no evidence that shaving in the opposite direction of hair growth will reduce folliculitis. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the manifestations, self-care, and nursing care of common skin problems and lesions. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 399
Question 4 Type: MCSA The nurse is counseling a patient who has atopic dermatitis (eczema) and has developed a secondary infection. What should the nurse emphasize so that the patient can prevent this type of infections in the future? 1. methods to prevent itching 2. continuous antibiotic treatment 3. frequent bathing 4. allergy testing Correct Answer: 1 Rationale 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. Rationale 2: Antibiotics would be given to treat the infection but not prevent it. Rationale 3: Frequent bathing may dry out the skin causing increased itching. Rationale 4: It is important to identify the irritants that cause the lesions, but this will not prevent a secondary infection. Global Rationale: 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. Antibiotics would be given to treat the
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
infection but not prevent it. Frequent bathing may dry out the skin causing increased itching. It is important to identify the irritants that cause the lesions, but this will not prevent a secondary infection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 406
Question 5 Type: MCSA A patient has a small, red, scaling lesion that is sitting on an elevated base on the forehead. The patient states that 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 Correct Answer: 1 Rationale 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. Rationale 2: Melanomas appear as a changing or unusual mole with an irregular border, an uneven surface, and a varying size and shape. Rationale 3: Psoriasis lesions are erythematous papules and plaques with silver-white scales that are sharply demarcated. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Seborrheic keratosis lesions are warty, dirty yellow to black papules with sharp margins. Global Rationale: 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. Melanomas appear as a changing or unusual mole with an irregular border, an uneven surface, and a varying size and shape. Psoriasis lesions are erythematous papules and plaques with silver white scales that are sharply demarcated. Seborrheic keratosis lesions are warty, dirty yellow to black papules with sharp margins. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 411
Question 6 Type: MCSA A patient diagnosed with scabies asks the nurse how he “caught” the disorder. 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. Correct Answer: 1 Rationale 1: Scabies is transmitted via contact with infected people or their contaminated articles. Rationale 2: Scabies is the result of infestation of the itch mite. Rationale 3: Scabies is a parasitic disorder. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: Scabies is not a bacterial, viral, or fungal disorder. Global Rationale: Scabies is transmitted via contact with infected people or their contaminated articles. It is the result of infestation of the itch mite. Scabies is a parasitic disorder. It is not a bacterial, viral, or fungal disorder. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 401
Question 7 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Herpes zoster can only be prevented or reduced by having the varicella vaccination. Rationale 3: Itchiness might occur when the lesions begin to heal; however, the priority is to treat the pain. Rationale 4: Herpes zoster does not occur because of poor hygiene. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Herpes zoster can only be prevented or reduced by having the varicella vaccination. Itchiness might occur when the lesions begin to heal; however, the priority is to treat the pain. Herpes zoster does not occur because of poor hygiene. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 403
Question 8 Type: MCSA The patient with herpes zoster has pruritus and reports difficulty resting at night. Which intervention will best aid the patient? 1. Encourage the patient 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. Correct Answer: 1 Rationale 1: The 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. Rationale 2: Although lotion may be prescribed for the lesions, it should not be massaged into the skin. Rationale 3: Powder can irritate the skin lesions. Rationale 4: Heat will increase the occurrence of itching. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: The 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. Lotion massaged into the skin and powder can irritate the skin lesions. Heat will increase the occurrence of itching. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 403
Question 9 Type: MCMA A patient at risk for the development of skin cancer is discussing sun exposure prevention with the nurse. What information should be included in the discussion? Standard Text: Select all that apply. 1. A higher-rated sunscreen is needed between 10 a.m. and 3 p.m. 2. Sunscreen is needed even on cloudy days. 3. Apply a sunscreen with an SPF of 15 or more. 4. The higher the sunscreen rating, the less the protection provided. 5. When swimming, sunscreen should be reapplied every 4 hours. Correct Answer: 1, 2, 3 Rationale 1: Sun exposure is greatest between 10 a.m. and 3 p.m. Rationale 2: Sun exposure is possible on both cloudy and sunny days. Rationale 3: The higher the level of the sunscreen’s rating, the greater the protection, but a minimum of 15 is recommended. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: The higher the level of the sunscreen’s rating, the greater the protection, but a minimum of 15 is recommended. Rationale 5: When swimming, sunscreen should be reapplied hourly. Global Rationale: Sun exposure is greatest between 10 a.m. and 3 p.m. Sun exposure is possible on both cloudy and sunny days. The higher the level of the sunscreen’s rating, the greater the protection, but a minimum of 15 is recommended. When swimming, sunscreen should be reapplied hourly. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 413
Question 10 Type: MCMA The nurse is planning care for a patient at risk for pressure ulcer development. What should the nurse include in this patient’s plan of care? Standard Text: 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 donut rings to reduce pressure on the sacrum. 5. Use hot water to cleanse the skin immediately after incontinence. Correct Answer: 1, 2
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. Rationale 2: The patient should be turned at least every 2 hours. Rationale 3: Massage of pressure areas can cause friction and damage to problem skin areas. Rationale 4: Inflatable donut rings are contraindicated, as they increase pressure and reduce perfusion to affected areas. Rationale 5: Use of hot water for cleansing may cause skin injury. Global Rationale: Urine and feces are destructive to skin. A frequent toileting schedule will reduce periods of incontinence and potential for skin breakdown. The patient should be turned at least every 2 hours. Massage of pressure areas can cause friction and damage to problem skin areas. Inflatable donut rings are contraindicated, as they increase pressure and reduce perfusion to affected areas. Use of hot water for cleansing may cause skin injury. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the risk factors for, pathophysiology of, and nursing interventions to prevent and care for pressure ulcers. MNL Learning Outcome: 4.3.1. Explain the incidence, risk factors, and prevention of pressure ulcers. Page Number: 423-424
Question 11 Type: MCMA The nurse understands that certain patients are more susceptible to pressure ulcer development. Which patients should the nurse identify as being at an increased risk for this health problem? Standard Text: Select all that apply. 1. patient with restricted activity 2. patient with decreased sensation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. patient who is very thin 4. patient with urinary and fecal incontinence 5. patient with good nutrition Correct Answer: 1, 2, 3, 4 Rationale 1: Patients who have restricted activity, as would occur with quadriplegia, strokes, and fractured hips, are at risk for pressure ulcer development. Rationale 2: Decreased sensation prevents patients from feeling the pain associated with the development of a pressure ulcer, which increases the risk of development and progression. Rationale 3: Patients who are very thin or have decreased protein in the diet have skin that is more likely to ulcerate. Rationale 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 ulcers. Rationale 5: Patients with good nutrition are at a decreased risk for pressure ulcer formation. Global Rationale: Patients who have restricted activity, as would occur with quadriplegia, strokes, and fractured hips, are at risk for pressure ulcer development. Decreased sensation prevents patients from feeling the pain associated with the development of a pressure ulcer, which increases the risk of development and progression. Patients who are very thin or have decreased protein in the diet have skin that is more likely to ulcerate. 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 ulcers. Patients with good nutrition are at a decreased risk for pressure ulcer formation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the risk factors for, pathophysiology of, and nursing interventions to prevent and care for pressure ulcers. MNL Learning Outcome: 4.3.1. Explain the incidence, risk factors, and prevention of pressure ulcers. Page Number: 420
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 12 Type: MCMA The nurse is assessing a patient’s risk for pressure ulcer development. Which factors should the nurse include in this assessment? Standard Text: Select all that apply. 1. sensory perception 2. moisture 3. mobility 4. nutrition 5. social interaction Correct Answer: 1, 2, 3, 4 Rationale 1: Decreased sensation increases the risk for pressure ulcer development. Rationale 2: Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development. Rationale 3: Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area. Rationale 4: Nutrition supplementation is an essential intervention for pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization. Rationale 5: The patient’s social interaction is not a risk level since a chair-bound person may socialize a lot, but not move. Global Rationale: Decreased sensation increases the risk for pressure ulcer development. Decreased activity increases the risk for pressure ulcer development due to prolonged pressure in one area, thereby decreasing the circulation to that area, resulting in decreased oxygen supply. Moisture increases skin breakdown, thereby increasing the risk for pressure ulcer development. Decreased mobility level increases the risk for pressure ulcer development due to prolonged pressure in one area. Nutrition supplementation is an essential intervention for pressure ulcer development. Protein is the building block for collagen synthesis, interstitial fluid balance, granulation, and epithelialization. The patient’s social interaction is not a risk level since a chair-bound person may socialize a lot, but not move. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the risk factors for, pathophysiology of, and nursing interventions to prevent and care for pressure ulcers. MNL Learning Outcome: 4.3.1. Explain the incidence, risk factors, and prevention of pressure ulcers. Page Number: 423
Question 13 Type: MCMA The nurse is planning care for a patient who is at risk for pressure ulcer development. Which action should be included in this patient’s plan of care? Standard Text: 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. Correct Answer: 1, 2, 3 Rationale 1: Pillows provide a cushion for bony prominences, which decreases pressure. Rationale 2: Turning every 2 hours takes prolonged pressure off a single area. Rationale 3: Mild cleansing agents are less likely to remove the skin’s natural barrier. Rationale 4: Keeping a patient on bed rest would be inappropriate because activity and mobility prevent prolonged pressure in one area. Rationale 5: Pulling patients up in bed increases friction and shear but does not prevent pressure.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Pillows provide a cushion for bony prominences, which decreases pressure. Turning every two hours takes prolonged pressure off a single area. Mild cleansing agents are less likely to remove the skin’s natural barrier. Keeping a patient on bed rest would be inappropriate because activity and mobility prevent prolonged pressure in one area. Pulling patients up in bed increases friction and shear, but does not prevent pressure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 3. Explain the risk factors for, pathophysiology of, and nursing interventions to prevent and care for pressure ulcers. MNL Learning Outcome: 4.3.4. Utilize the nursing process in care of client. Page Number: 423
Question 14 Type: MCSA A patient asks the nurse about possible options regarding treatment for 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” Correct Answer: 1 Rationale 1: Surgical excision is the preferred treatment for malignant melanoma. Rationale 2: A topical cream would not be used for a melanoma. Rationale 3: Radiation is most often used for lesions that are inoperable because of location, which is not the case here. Rationale 4: Intravenous chemotherapy would not be used for a localized skin lesion. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Surgical excision is the preferred treatment for malignant melanoma. A topical cream would not be used for a melanoma. Radiation is most often used for lesions that are inoperable because of location, which is not the case here. Intravenous chemotherapy would not be used for a localized skin lesion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 415
Question 15 Type: MCMA A patient with a basal cell carcinoma of the nose will be having the lesion removed by curettage and electrodesiccation. The nurse knows that the lesion must meet what criteria for this type of procedure? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: Curettage and electrodesiccation are used to treat basal cell carcinomas that are less than 2 cm in diameter. Rationale 2: Curettage and electrodesiccation are used to treat basal cell carcinomas that are superficial. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Curettage and electrodesiccation are not used for lesions that are larger. Rationale 4: Curettage and electrodesiccation are not used where the dermis is thin. Rationale 5: Curettage and electrodesiccation are not where the tumor extends into the subcutaneous tissue. Global Rationale: Curettage and electrodesiccation are used to treat basal cell carcinomas that are less than 2 cm in diameter, are superficial, or reoccur because of poor margin control. Curettage and electrodesiccation are not used for lesions that are larger, where the dermis is thin, or where the tumor extends into the subcutaneous tissue. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 412
Question 16 Type: MCMA 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? Standard Text: 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.” Correct Answer: 1, 2, 3 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Depending on the depth of the lesion, it may take a short time or a long time. Rationale 3: It is difficult to predict in advance. Rationale 4: There is no way of knowing how long the procedure will take to complete. Rationale 5: There is no way of knowing how long the procedure will take to complete. Global Rationale: Mohs surgery involves shaving thin layers of the tumor off and frozen tissue analysis at each stage. 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. It is difficult to predict in advance. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 412
Question 17 Type: MCMA A patient has had cryosurgery to treat a skin lesion. What instructions should be given to the patient and family on discharge? Standard Text: 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Healing may take several weeks. 5. Healing should occur in a few days. Correct Answer: 1, 2, 3, 4 Rationale 1: It may take 24 hours for the effects to become obvious. Rationale 2: Postoperatively, infection is prevented by applying a topical antibiotic. Rationale 3: Postoperatively, infection is prevented by keeping the treated areas clean. Rationale 4: Healing occurs in 2 to 3 weeks. Rationale 5: Healing occurs in 2 to 3 weeks. Global Rationale: Cryosurgery involves using cold or a freezing agent that destroys the tissue. It may take 24 hours for the effects to become obvious. Postoperatively, infection is prevented by applying a topical antibiotic and keeping the treated areas clean. Healing occurs in 2 to 3 weeks. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 425
Question 18 Type: MCSA A patient is recovering from surgery to remove a large skin cancer and has a skin graft in place to cover the wound area. Consider the following menus and select the one that would be most beneficial for this patient’s healing.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. Diet 1 2. Diet 2 3. Diet 3 4. Diet 4 Correct Answer: 1 Rationale 1: A diet high in protein, ascorbic acid, vitamins, and minerals is necessary for tissue repair, collagen formation, and wound strength. Diet 1 has protein in the chicken and baked beans, ascorbic acid in the oranges and strawberries, and vitamins and minerals particularly in the salad, fruit, and baked beans. Rationale 2: This diet is lower in protein and has little ascorbic acid. Rationale 3: This diet is lower in protein and has little ascorbic acid. Rationale 4: This diet is lower in protein and has little ascorbic acid. Global Rationale: A diet high in protein, ascorbic acid, vitamins, and minerals is necessary for tissue repair, collagen formation, and wound strength. Diet 1 has protein in the chicken and baked beans, ascorbic acid in the oranges and strawberries, and vitamins and minerals particularly in the salad, fruit, and baked beans. The other diets are lower in protein and have little ascorbic acid. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 427
Question 19 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Cotton undergarments would not impact tinea pedis. They could assist in the management of tinea corporis. Rationale 3: Salt water is not associated with the management of tinea pedis. Rationale 4: Lotions would increase moisture to the areas and potentially cause additional problems. Global Rationale: 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. Cotton undergarments would not impact tinea pedis. They could assist in the management of tinea corporis. Salt water is not associated with the management of tinea pedis. Lotions would increase moisture to the areas and potentially cause additional problems. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin.. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 400
Question 20 Type: MCMA Several individuals from a homeless shelter have been diagnosed with pediculosis. The nurse, planning to train staff on the control and prevention of this contagious infection, should include what information? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: Pediculosis is a contagious infestation with lice transmitted by personal contact. It can be spread through combs, animals, hats, blankets, telephones, and theater seats. Rationale 2: Pediculosis is more common in people with lack of proper facilities for bathing and washing clothes. Rationale 3: Pediculosis can be spread through combs, animals, hats, blankets, telephones, and theater seats. Rationale 4: Anyone can contract pediculosis.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Infestation by mites is scabies, not pediculosis. Global Rationale: Pediculosis is a contagious infestation with lice transmitted by personal contact. It can be spread through combs, animals, hats, blankets, telephones, and theater seats. It often occurs in individuals who do not have access to facilities for bathing or washing clothes such as the homeless. Anyone can contract pediculosis. Infestation by mites is scabies, not pediculosis. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the pathophysiology of selected disorders of the hair and nails. MNL Learning Outcome: 4.1.1. Explain the pathophysiology of inflammatory and infectious skin disorders. Page Number: 401
Question 21 Type: MCMA The nurse is reading the history and physical records of a patient who has alopecia. What should the nurse recognize as possible causes for this disorder? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: Systemic causes of alopecia can include thyroid disorders. Rationale 2: Systemic causes of alopecia can include systemic lupus erythematosus. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Numerous drugs can cause alopecia, including many chemotherapeutic drugs used to treat cancer. Rationale 4: Hair loss from androgenic causes may occur in postmenopausal women. Rationale 5: Systemic causes of alopecia can include pituitary insufficiency, not pituitary oversecretion. Global Rationale: Systemic causes of alopecia can include thyroid disorders, systemic lupus erythematosus or pituitary insufficiency, not pituitary oversecretion. Numerous drugs can cause alopecia, including many chemotherapeutic drugs used to treat cancer. Hair loss from androgenic causes may occur in postmenopausal women. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 5. Explain the pathophysiology of selected disorders of the hair and nails. MNL Learning Outcome: 4.4.1. Explain the pathophysiology of hair and nail disorders. Page Number: 428
Question 22 Type: MCSA For several months a patient has been experiencing an infection of the cuticle involving several fingernails on both hands. The nurse should recognize this condition as being related to what type of employment? 1. dish washer 2. construction worker 3. painter 4. carpenter Correct Answer: 1 Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. Construction workers, painters, and 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 5. Explain the pathophysiology of selected disorders of the hair and nails. MNL Learning Outcome: 4.4.1. Explain the pathophysiology of hair and nail disorders. Page Number: 429
Question 22 Type: MCMA A female patient is prescribed tretinoin (Retin-A). What should the nurse instruct the patient about this medication? Standard Text: 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Apply to clean, dry skin. 5. Use a reliable form of contraception one month prior to and during use of the medication. Correct Answer: 1, 4 Rationale 1: The medication could cause hypersensitivity to sun. Rationale 2: There is no reason to avoid the use of vitamin A supplements. Rationale 3: There is no need to exercise caution during night driving when using this medication. Rationale 4: The medication should be applied to clean, dry skin. Rationale 5: There is no need to alter birth control approaches when using this medication. Global Rationale: The medication could cause hypersensitivity to sun. There is no reason to avoid the use of vitamin A supplements. There is no need to exercise caution during night driving when using this medication. The medication should be applied to clean dry skin. There is no need to alter birth control approaches when using this medication. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 408
Question 23 Type: MCSA A patient diagnosed 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. Avoid rubbing into the skin. 3. Apply a thick layer. 4. Continue medication even if lesions worsen Correct Answer: 1 Rationale 1: Topical corticosteroids should be applied in a thin layer. Rationale 2: Topical corticosteroids should be rubbed in thoroughly on wet skin. Rationale 3: Topical corticosteroids should be applied in a thin layer. Rationale 4: Some infections may be made worse by corticosteroids. If the lesions worsen, the medication should be discontinued and the health provider notified. Global Rationale: Topical corticosteroids should be applied in a thin layer and rubbed in thoroughly on wet skin. Some infections may be made worse by corticosteroids. If the lesions worsen, the medication should be discontinued and the health provider notified. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 395
Question 24 Type: MCMA 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? Standard Text: Select all that apply. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. ice cream 2. cheese 3. crackers 4. pretzels 5. alcohol Correct Answer: 1, 2 Rationale 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. Rationale 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. Rationale 3: Crackers and pretzels are high-carbohydrate, lower fat foods. Rationale 4: Crackers and pretzels are high-carbohydrate, lower fat foods. Rationale 5: Alcohol should be avoided since it may cause rapid pulse and flushing in patients prescribed griseofulvin. Global Rationale: The medication should be taken with meals or food high in fat to avoid stomach upset and to help with absorption such as ice cream or cheese. Crackers and pretzels are high-carbohydrate, but lower fat foods. Alcohol should be avoided since it may cause rapid pulse and flushing in patients prescribed griseofulvin. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 400
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 25 Type: MCSA A patient with a history of pruritis says, “The itching seems to improve when I take my allergy medicine.” The nurse realizes that this is most likely because 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. Correct Answer: 1 Rationale 1: The irritant that causes the itching releases histamine. Antihistamines may relieve pruritis for some patients. Rationale 2: The allergies are the cause of the itching. Rationale 3: Pruritis is improving as a result of the medication blocking the histamine release. Rationale 4: There is no indication the patient is taking other medications. Global Rationale: The irritant that causes the itching releases histamine. Antihistamines may relieve pruritis for some patients. The allergies are the cause of the itching. Pruritis is improving as a result of the medication blocking the histamine release. There is no indication the patient is taking other medications. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Evaluation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 391
Question 26 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA A 47-year-old female patient with a history of sun exposure is concerned that she has a disease because of 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 Correct Answer: 1 Rationale 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. Rationale 2: Nevus flammeus is a congenital vascular condition involving the capillaries. Rationale 3: Venus lakes are small, flat, blue blood vessels. Rationale 4: Skin tags are soft papules on a pedicle. Global Rationale: 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. Nevus flammeus is a congenital vascular condition involving the capillaries. Venus lakes are small, flat, blue blood vessels. Skin tags are soft papules on a pedicle. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 1. Describe the manifestations, self-care, and nursing care of common skin problems and lesions. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 393
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 27 Type: MCSA A patient is receiving his 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. Correct Answer: 1 Rationale 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. Rationale 2: The treatment is measured in seconds with a gradual increase in exposure times. Rationale 3: To avoid damage to the eyes, they will need to be shielded during the treatment. Rationale 4: Patients with generalized psoriasis or with psoriasis over 30% of the body will most likely be treated with phototherapy. Global Rationale: Patients with generalized psoriasis or with psoriasis over 30% of the body will most likely be treated with phototherapy. To avoid damage to the eyes, they will need to be shielded during the treatment and the patient can expect areas of erythema approximately eight hours after the treatment. The treatment is measured in seconds with a gradual increase in exposure times. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 395 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 28 Type: MCSA A female patient comes into the clinic with eyelid redness and edema. What would be appropriate for the nurse to include in the assessment of this patient? 1. Ask the patient if she has been thoroughly removing all her eye makeup. 2. Ask if the patient has recently been in a public swimming pool. 3. Ask the patient if she shaves her legs. 4. Ask the patient if she has recently changed her facial soap. Correct Answer: 1 Rationale 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. Rationale 2: An infection caused by the swimming pool would encompass the entire body. Rationale 3: Shaving would involve the legs. Rationale 4: The complaints are not generalized on the face but localized in the eye area, so the facial soap is not the culprit. Global Rationale: 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. The patient’s complaints are in the orbital area. An infection caused by the swimming pool would encompass the entire body. Shaving would involve the legs. The complaints are not generalized on the face but localized in the eye area, so the facial soap is not the culprit. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 397, 399
Question 29 Type: MCSA The mother of a 12-year-old child reports that her daughter frequently scratches her scalp and the hair “is clumpy and smells really bad.” What should the nurse do to assist this mother? 1. Suggest that the daughter be checked for head lice. 2. Suggest that the daughter have a blood glucose level drawn. 3. Suggest that the daughter wash her hair. 4. Suggest that the daughter have a haircut. Correct Answer: 1 Rationale 1: Pediculosis capitis is an infestation with head lice. It is more common in female children. 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. Rationale 2: There are no indications from the information provided that the child has diabetes. Rationale 3: Although hygiene may be an issue, the greatest indicator points toward the presence of head lice. Rationale 4: There is no need to encourage a haircut at this time. Global Rationale: Pediculosis capitis is an infestation with head lice. It is more common in female children. 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. There are no indications from the information provided that the child has diabetes. Although hygiene may be an issue, the greatest indicator points toward the presence of head lice. There is no need to encourage a haircut at this time. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 401
Question 30 Type: MCSA A 68-year-old male patient comes into the clinic with a “strange painful rash” located on the left side of his upper chest. The nurse realizes that this patient might be experiencing what health problem? 1. herpes zoster 2. herpes simplex 3. verruca plana 4. condylomata acuminata Correct Answer: 1 Rationale 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. Rationale 2: Herpes simplex is usually located on the face, mouth, or genital regions. Rationale 3: The clinical manifestations that this patient reports are inconsistent with verruca. Rationale 4: The clinical manifestations that this patient reports are inconsistent with condylomata. Global Rationale: 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. Herpes simplex is usually located on the face, mouth, or genital regions. The clinical manifestations that this patient reports are inconsistent with verruca or condylomata. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 402
Question 31 Type: MCSA A female patient comes into the clinic with an itchy reddened area on both hands. Which technique should the nurse use when assessing this patient? 1. Ask the patient if she has changed soap or perfume. 2. Ask the patient to remove her shoes and stockings. 3. Listen to the patient’s lungs. 4. Assess the patient’s hand grasp strength. Correct Answer: 1 Rationale 1: This patient’s description fits that of 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. Rationale 2: There are no reports of the rash on her legs or feet. Rationale 3: Respiratory complications are not present. Rationale 4: It is not necessary to assess this patient’s musculoskeletal strength. Global Rationale: This patient’s description fits that of 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. There are no reports of the rash on her legs or feet. Respiratory complications are not present. It is not necessary to assess this patient’s musculoskeletal strength. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 406
Question 32 Type: MCSA A 57-year-old female patient complains of “strange pimples” over her buttocks region. The nurse realizes that this patient might be experiencing which health problem? 1. acne conglobata 2. contact dermatitis 3. acne vulgaris 4. acne rosacea Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: Acne vulgaris is found in preteens, teens, and young adults and occurs on the face and shoulders. Rationale 4: Acne rosacea appears as a red, blotchy area and is limited to the face. Global Rationale: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
occurs primarily on the back, buttocks, and chest. 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. Acne vulgaris is found in preteens, teens, and young adults, and occurs on the face and shoulders. Acne rosacea appears as a red, blotchy area and is limited to the face. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 407
Question 33 Type: MCMA The nurse is preparing a teaching plan about acne for a group of community teenagers. What should be included in this teaching plan? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: The teaching plan for the patient with acne should include exposing the skin to sunlight but avoiding sunburn. Rationale 2: The teaching plan for the patient with acne should include shampooing the hair often enough to prevent oiliness. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 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. Rationale 5: The teaching plan for the patient with acne should include trying to avoid putting hands on the face and not squeezing pimples. Global Rationale: The teaching plan for the patient with acne should include exposing the skin to sunlight but avoiding sunburn; shampooing the hair often enough to prevent oiliness; eating a regular, well-balanced diet as foods do not cause or increase acne; washing the skin with a mild soap and water at least twice a day; getting regular exercise and sleep; avoiding putting hands on the face; and not squeezing pimples. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Describe the manifestations, self-care, and nursing care of common skin problems and lesions. MNL Learning Outcome: 4.1.4. Utilize the nursing process in care of client. Page Number: 408
Question 34 Type: MCSA A 52-year-old male patient of English descent is diagnosed with basal cell cancer on the face and forehead. What should the nurse include when teaching this patient about his 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. Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Basal cell cancer tends to reoccur. Tumors larger than 2 cm have a high rate of return. Rationale 2: Basal cell cancer is the least aggressive type of skin cancer. Malignant melanoma is the most virulent form of skin cancer. Rationale 3: No cancer should be left alone. Rationale 4: Basal cell cancer is the most common type of skin cancer. Global Rationale: Basal cell cancer tends to reoccur. Tumors larger than 2 cm have a high rate of return. Basal cell cancer is the most common but least aggressive type of skin cancer. No cancer should be left alone. Malignant melanoma is the most virulent form of skin cancer. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.1. Explain the pathophysiology of non-malignant and malignant skin disorders. Page Number: 411
Question 35 Type: MCSA A patient with skin cancer is recovering from a surgical procedure in which the layers of the lesion were shaved off. The nurse realizes that this patient most likely had which procedure? 1. Mohs surgery 2. complete surgical excision of the lesion 3. curettage 4. electrodesiccation Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: A surgical excision is the total removal of the lesion, not just layers. Rationale 3: Curettage is the shaving of abnormal tissue within 1 to 2 mm of the margin. Rationale 4: Electrodesiccation refers to the use of a low-voltage transmission to the base of the tumor. Global Rationale: 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. A surgical excision is the total removal of the lesion not just layers. Curettage is the shaving of abnormal tissue within 1 to 2 mm of the margin. Electrodesiccation refers to the use of a low-voltage transmission to the base of the tumor. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Evaluation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 412
Question 36 Type: MCSA A 35-year-old female patient is diagnosed with advanced malignant melanoma. The nurse realizes that this patient: 1. has an uncertain prognosis. 2. has a poor prognosis due to her age. 3. will be completely cured with surgery. 4. will need chemotherapy and radiation. Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: The prognosis for survival for people diagnosed with malignant melanoma is determined by tumor thickness, ulceration, metastasis, site, age, and gender. Rationale 2: Younger patients and women have a somewhat better chance of survival. Rationale 3: There is no evidence that the patient will be completely cured with surgery. Rationale 4: There is no evidence that the patient will need chemotherapy and radiation. Global Rationale: The prognosis for survival for people diagnosed with malignant melanoma is determined by tumor thickness, ulceration, metastasis, site, age, and gender. Younger patients and women have a somewhat better chance of survival. There is no evidence that the patient will be completely cured with surgery or will need chemotherapy and radiation. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Planning Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 414
Question 37 Type: MCSA 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 Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Dietary alterations will not help with insufficient blood flow. Rationale 3: Dietary alterations will not help with oxygenation. Rationale 4: Fluid volume is not directly impacted by a diet high in protein and calories. Global Rationale: 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. Dietary alterations will not help with insufficient blood flow or oxygenation. Fluid volume is not directly impacted by a diet high in protein and calories. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 417
Question 38 Type: MCSA 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. Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Pulling up the patient when in bed subjects the patient to shearing forces. Rationale 3: Sliding the patient when in bed subjects the patient to shearing forces. Rationale 4: Doing nothing is not appropriate for the patient confined to bed. Global Rationale: 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. Doing nothing is not appropriate for the patient confined to bed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 3. Explain the risk factors for, pathophysiology of, and nursing interventions to prevent and care for pressure ulcers. MNL Learning Outcome: 4.3.1. Explain the incidence, risk factors, and prevention of pressure ulcers. Page Number: 420
Question 39 Type: MCSA A patient in a wheelchair has a history of sacral pressure ulcer formation. What instruction should be included in the patient’s teaching? 1. Shift the weight every 15 minutes to 1 hour. 2. Sit on a donut. 3. Stay in one position as long as possible. 4. Have a family pull the patient up in the wheelchair. Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Avoid the use of donut devices because they cause a reduction in blood perfusion and contribute to pressure ulcer formation. Rationale 3: Sitting uninterrupted in a wheelchair should be avoided. Rationale 4: Pulling the patient up in the chair may result in skin shear. Global Rationale: The patient should be repositioned every hour. If the patient can move, teach him or her to shift the weight every 15 minutes. Avoid the use of donut devices because they cause a reduction in blood perfusion and contribute to pressure ulcer formation. Sitting uninterrupted in a wheelchair should be avoided. Pulling the patient up in the chair may result in skin shear. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain the risk factors for, pathophysiology of, and nursing interventions to prevent and care for pressure ulcers. MNL Learning Outcome: 4.3.1. Explain the incidence, risk factors, and prevention of pressure ulcers. Page Number: 424
Question 40 Type: MCSA A 40-year-old 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 Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Chemical peeling involves a process that smoothes the skin by removing the surface layers. Rationale 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. Rationale 4: Blepharoplasty is a cosmetic surgical procedure on the eyes. This cannot be used to remove the tattoos. Global Rationale: 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. Chemical peeling involves a process that smoothes the skin by removing the surface layers. 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. Blepharoplasty is a cosmetic surgical procedure on the eyes. This cannot be used to remove the tattoos. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 426
Question 41 Type: MCSA A 55-year-old patient who is 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.” LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. “What did you expect?” Correct Answer: 1 Rationale 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. Rationale 2: The use of makeup is not needed and is premature. Rationale 3: Filing a complaint with the doctor is not indicated. Rationale 4: The patient’s emotional state warrants an empathetic response; asking the patient what he or she expected is not a therapeutic response. Global Rationale: 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. The use of makeup is not needed and is premature. Filing a complaint with the doctor is not indicated. The patient’s emotional state warrants an empathetic response; asking the patient what he or she expected is not a therapeutic response. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 427
Question 42 Type: MCSA A patient with a history of basal cell skin cancer asks the nurse what to do to avoid having the cancer recur. What should the nurse instruct this patient? 1. Always use a sunscreen of SPF 15 or higher. 2. Avoid the sun at all costs. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
3. Sun exposure between the hours of 10:00 am and 3:00 pm is best. 4. Sunscreen is not needed on cloudy days. Correct Answer: 1 Rationale 1: Always use a sunscreen of SPF 15 or higher. Rationale 2: It is unrealistic to instruct a patient to always avoid the sun. Rationale 3: The hours of 10:00 am to 3:00 pm are the worst for sun exposure. Rationale 4: Sunscreen is needed even on cloudy days. Global Rationale: The patient should be instructed on the use of a sunscreen of SPF 15 or higher. It is unrealistic to instruct a patient to always avoid the sun. The hours of 10:00 am to 3:00 pm are the worst for sun exposure. Sunscreen is needed even on cloudy days. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the etiology, pathophysiology, interprofessional care, and nursing care of patients with infections and infestations, inflammatory disorders, and malignancies of the skin. MNL Learning Outcome: 4.2.4. Utilize the nursing process in care of client. Page Number: 412-413
Question 43 Type: MCMA 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? Standard Text: Select all that apply.
1. Place a bath mat in the tub. 2. Stay in the tub bath for 1 hour. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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.
Correct Answer: 1, 3 Rationale 1: A bath mat should be used in the tub because medications may cause the tub to become slippery. Rationale 2: The patient should be instructed to stay in the tub for 20 to 30 minutes and immerse the area being treated. Rationale 3: The bathroom should be well-ventilated when using medications in a bath. Rationale 4: The skin should be blotted and not rubbed with a towel. Rationale 5: If itching is not relieved or becomes worse, the health care provider should be contacted.
Global Rationale: A bath mat should be used in the tub because medications may cause the tub to become slippery. The patient should be instructed to stay in the tub for 20 to 30 minutes and immerse the area being treated. The bathroom should be well-ventilated when using medications in a bath. The skin should be blotted and not rubbed with a towel. If itching is not relieved or becomes worse, the health care provider should be contacted. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 392
Question 44 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient with psoriasis is prescribed photochemotherapy treatments. What should the nurse teach the patient about future health risks caused by this treatment?
Standard Text: 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.
Correct Answer: 1, 3, 4, 5 Rationale 1: Photochemotherapy can accelerate aging of exposed skin. Rationale 2: Photochemotherapy has had a high success rate in achieving remission of psoriasis. Rationale 3: Photochemotherapy can alter immune function. Rationale 4: Photochemotherapy can induce cataract development. Rationale 5: Photochemotherapy can increase the risk of melanoma. Global Rationale: Photochemotherapy can accelerate aging of exposed skin, induce cataract development, alter immune function, and increase the risk of melanoma. It has a high success rate in achieving remission of psoriasis. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 395
Question 45 Type: MCMA A patient with a skin infection is diagnosed with methicillin-resistant Staphylococcus aureus (MRSA). What mediations should the nurse expect to be prescribed for this patient?
Standard Text: Select all that apply.
1. penicillin (Pen-V-K) 2. clindamycin (Cleocin) 3. minocycline (Minocin) 4. doxycycline (Vibramycin) 5. trimethoprimsulfamethoxazole (Bactrim)
Correct Answer: 2, 3, 4, 5 Rationale 1: Penicillin (Pen-V-K) is not used to treat MRSA infections. Rationale 2: MRSA infections may be treated with antimicrobial therapy, including clindamycin (Cleocin). Rationale 3: MRSA infections may be treated with antimicrobial therapy, including minocycline (Minocin). Rationale 4: MRSA infections may be treated with antimicrobial therapy, including doxycycline (Vibramycin). Rationale 5: MRSA infections may be treated with antimicrobial therapy, including trimethoprimsulfamethoxazole (Bactrim). Global Rationale: MRSA infections may be treated with antimicrobial therapy, including trimethoprimsulfamethoxazole (Bactrim), minocycline (Minocin), doxycycline (Vibramycin), or clindamycin (Cleocin). Penicillin (Pen-V-K) is not used to treat MRSA infections. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.1.3. Examine the diagnosis and treatment of inflammatory and infectious skin disorders. Page Number: 398
Question 46 Type: MCMA
A patient is being scheduled for diagnostic tests to determine the presence of pemphigus vulgaris. Which tests should the nurse expect to schedule for this patient?
Standard Text: Select all that apply.
1. curettage 2. skin biopsy 3. Wood’s lamp 4. Mohs procedure 5. immunofluorescence microscopy
Correct Answer: 2, 5 Rationale 1: Curettage is a method to treat skin cancer. Rationale 2: Pemphigus vulgaris is diagnosed by skin biopsy to determine the presence of acantholysis. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Wood’s lamp is a diagnostic test for fungal infections. Rationale 4: Mohs procedure is a method to treat skin cancer. Rationale 5: Pemphigus vulgaris is diagnosed by diagnostic tests, including immunofluorescence microscopy, which is done to identify the presence of IgG antibodies in the epidermis and serum. Global Rationale: Pemphigus vulgaris is diagnosed by diagnostic tests including immunofluorescence microscopy, which is done to identify the presence of IgG antibodies in the epidermis and serum, and skin biopsy to determine the presence of acantholysis. Curettage is a method to treat skin cancer. Wood’s lamp is a diagnostic test for fungal infections. Mohs procedure is a method to treat skin cancer. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 4. Discuss surgical options for excision of neoplasms, reconstruction of facial or body structures, and cosmetic procedures. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 408-409
Question 47 Type: MCMA A patient who was stranded during a snowstorm is admitted for frostbite of the fingers and toes. Which actions should the nurse expect to perform for this patient?
Standard Text: 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. Massage the fingers and toes for 10 minutes after warming. 5. Warm the digits with circulating water for 20 to 30 minutes.
Correct Answer: 1, 2, 5 Rationale 1: After rewarming the affected parts, they should be elevated. Rationale 2: Pain medications are provided as prescribed. Rationale 3: Elastic compression bandages are not used in the treatment of frostbite. Rationale 4: The affected areas should not be massaged. Rationale 5: Rapidly rewarm affected areas in circulating warm water, 40° to 40.5°C (104° to 105°F) for 20 to 30 minutes. Global Rationale: In the treatment of frostbite, after rewarming the affected parts, they should be elevated. Pain medications are provided as prescribed. Rapidly rewarm affected areas in circulating warm water, 40° to 40.5°C (104° to 105°F) for 20 to 30 minutes. Elastic compression bandages are not used in the treatment of frostbite. The affected areas should not be massaged. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I. A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 8. 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: Implementation Learning Outcome: 6. Discuss the nursing implications related to the actions and effects of medications and other treatments for the patient with a disorder of the integumentary system. MNL Learning Outcome: 4.2.3. Examine the diagnosis and treatment of non-malignant and malignant skin disorders. Page Number: 424
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 17 Question 1 Type: MCMA A patient comes into the emergency department with a chemical burn from contact with lye. Which facts about this type of burn should guide the nurse when assessing and planning care for this patient? Standard Text: 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. Correct Answer: 1, 2 Rationale 1: This is an alkali burn. Rationale 2: This is an alkali burn, which tends to penetrate more deeply. Rationale 3: This is not an acid burn. Rationale 4: This type of burn is more difficult to neutralize. Rationale 5: This type of burn tends to have a deeper penetration. Global Rationale: This is an alkali burn, which is more difficult to neutralize than an acid burn, tends to penetrate more deeply, and is harder to neutralize than a burn caused by an acid. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 1. Discuss the types and causative agents of burns. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 433 Question 2 Type: MCMA A patient arrives at the emergency department with an electrical burn. What assessment questions should the nurse ask when determining the possible severity of the burn injury? Standard Text: 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? Correct Answer: 1, 2, 3 Rationale 1: The severity of electrical burns depends on the type of current. Rationale 2: The severity of electrical burns depends on the duration of the current. Rationale 3: The severity of electrical burns depends on the amount of voltage. Rationale 4: Location is not important in determining possible severity. Rationale 5: Point of contact is not important in determining possible severity. Global Rationale: The severity of electrical burns depends on the type and duration of the current and the amount of voltage. Location and point of contact are not important in determining possible severity. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 1. Discuss the types and causative agents of burns. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 433 Question 3 Type: MCSA A nurse sees a patient get struck by lightning during a thunderstorm on a golf course. What is the first action the nurse should perform? 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. Correct Answer: 1 Rationale 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. Rationale 2: This is a secondary action. Rationale 3: This is a secondary action. Rationale 4: This is a secondary action. Global Rationale: Cardiopulmonary arrest is the most common cause of death from lightening. Respiratory and cardiac status should be assessed immediately to determine if CPR is necessary. All the other actions are secondary. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss the types and causative agents of burns. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 434 Question 4 Type: MCMA 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? Standard Text: Select all that apply. 1. drain cleaners 2. household ammonia 3. oven cleaner 4. toiler bowl cleaner 5. lemon oil furniture polish Correct Answer: 1,2,3,4 Rationale 1: Drain cleaners are chemical agents that can cause burns. Rationale 2: Household ammonia is a chemical agent that can cause burns. Rationale 3: Oven cleaners are chemical agents that can cause burns. Rationale 4: Toilet bowl cleaners are chemical agents that can cause burns. Rationale 5: Lemon oil furniture polish is not identified as a product that can cause chemical burns. Global Rationale: Drain cleaners, household ammonia, oven cleaners, and toilet bowl cleaners are household products containing chemicals that can cause burns. Lemon oil furniture polish is not identified as a product that can cause chemical burns. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Discuss the types and causative agents of burns. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 433 Question 5 Type: MCSA A patient with a burn that is pale, waxy, and with large flat blisters asks the nurse about the severity of the burn and how long it will take to heal. How should the nurse respond? 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. Correct Answer: 1 Rationale 1: The wound is a deep partial-thickness burn that often takes more than 3 weeks to heal. Rationale 2: The wound is a deeper than a superficial partial-thickness burn and will take more than 2 weeks to heal. Rationale 3: A superficial burn is pink to bright red, with a healing time of 3 to 6 days. Rationale 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. Global Rationale: The wound is a deep partial-thickness burn, which often takes more than 3 weeks to heal. A superficial partial-thickness burn is bright red and has a moist, glistening appearance with blister formation. This type of burn heals within 21 days. A superficial burn is pink to bright red, with a healing time of 3 to 6 days. A full-thickness burn involves all layers of the skin and may extend into the underlying tissue. These burns take many weeks to heal. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Explain burn classification by depth and extent of injury. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 435 Question 6 Type: MCMA The nurse is classifying a patient’s burn injuries. What information should the nurse assess to ensure this classification is correct? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 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. Rationale 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. Rationale 3: The causative agent is especially important with burns caused by chemicals such as strong acids or alkaline agents. Rationale 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. Rationale 5: Time of occurrence of the burn is not necessary for classification. Global Rationale: The depth of the burn (layers of underlying tissue affected) and extent of the burn (percentage of body surface area involved) are 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. The causative agent is especially important with burns caused by chemicals such as strong acids or alkaline agents. 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. Time of occurrence of the burn is not necessary for classification. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Explain burn classification by depth and extent of injury. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 433-434, 436 Question 7 Type: MCMA A patient has a scald burn on the arm that is bright red, moist, and has several blisters. The nurse would classify this burn as which type? Standard Text: Select all that apply. 1. a superficial partial-thickness burn 2. a thermal burn 3. a superficial burn 4. a deep partial-thickness burn 5. a full-thickness burn Correct Answer: 1, 2 Rationale 1: Superficial partial-thickness burns are often bright red, with a moist, glistening appearance and blister formation. Rationale 2: Thermal burns result from exposure to dry or moist heat. Rationale 3: A superficial burn is pink to bright red, with possible slight edema over the area. Rationale 4: A deep partial-thickness burn often appears waxy and pale and may be moist or dry. Rationale 5: A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or nonblanching red, with a dry, leathery, firm wound surface. Global Rationale: Superficial partial-thickness burns are often bright red, with a moist, glistening appearance and blister formation. Thermal burns result from exposure to dry or moist heat. A superficial burn is pink to bright red, LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
with possible slight edema over the area. A deep partial-thickness burn often appears waxy and pale and may be moist or dry. A full-thickness burn may appear pale, waxy, yellow, brown, mottled, charred, or nonblanching red, with a dry, leathery, firm wound surface. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Explain burn classification by depth and extent of injury. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 433, 435 Question 8 Type: FIB A patient is brought to the emergency department with 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. __ _ % Standard Text: Record your answer rounding to the nearest whole number. Correct Answer: 23 Rationale: 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%. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Explain burn classification by depth and extent of injury. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 436 Question 9 Type: MCSA A 25-year-old patient is admitted with 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 Correct Answer: 1 Rationale 1: A moderate burn injury is a partial-thickness burn involving 15%–25% of total body surface area in adults. Rationale 2: A minor burn injury is a partial-thickness burn involving less than 15% of total body surface area (TBSA) in adults. Rationale 3: A major burn injury is a partial-thickness burn involving more than 25% of total body surface area (TBSA) in adults Rationale 4: Severe is not a term used in burn injury classifications. Global Rationale: A moderate burn injury is a partial-thickness burn involving 15%–25% of total body surface area in adults. A minor burn injury is a partial-thickness burn involving less than 15% of total body surface area (TBSA) in adults. A major burn injury is a partial-thickness burn involving more than 25% of the total body surface area (TBSA) in adults. Severe is not a term used in burn injury classifications. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Compare and contrast the pathophysiology and interprofessional care of a minor burn and a major burn. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 438 Question 10 Type: MCSA 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 Correct Answer: 1 Rationale 1: Partial-thickness burn injuries of greater than 25% of TBSA in adults and full-thickness injuries 10% or greater of TBSA are considered major burn injuries. Rationale 2: Moderate burn injuries comprise partial-thickness burns of 15%–25% of TBSA in adults and fullthickness injuries greater than 10% of TBSA not involving ears, eyes, face, hands, feet, and perineum. Rationale 3: Minor burn injuries comprise partial-thickness burns of less than 15% of TBSA in adults and fullthickness injuries less than 2% of TBSA not involving ears, eyes, face, hands, feet, and perineum. Rationale 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. Global Rationale: Partial-thickness burn injuries of greater than 25% of TBSA in adults and full-thickness injuries 10% or greater of TBSA are considered major burn injuries. Moderate burn injuries comprise partialthickness 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. 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. 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Compare and contrast the pathophysiology and interprofessional care of a minor burn and a major burn. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 438 Question 11 Type: MCSA A 70-year-old patient is sunburned over much of the body. What self-care technique is MOST important to emphasize to an older adult to deal with the effects of sunburn? 1. increasing fluid intake 2. applying mild lotions 3. taking mild analgesics 4. maintaining warmth Correct Answer: 1 Rationale 1: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. Rationale 2: Applying lotion may help alleviate the manifestation of skin redness from sunburn, but another selfcare technique is more critical. Rationale 3: Taking mild analgesics may help alleviate the manifestations of pain and headache from sunburn, but another self-care technique is more critical. Rationale 4: Maintaining warmth may help alleviate the manifestation of chills from sunburn, but another selfcare technique is more critical. Global Rationale: Older adults are especially prone to dehydration; therefore, increasing fluid intake is especially important. The other measures help alleviate the manifestations of this minor burn, which include pain, skin redness, chills, and headache. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 3. Compare and contrast the pathophysiology and interprofessional care of a minor burn and a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 438 Question 12 Type: MCMA A patient is being discharged after treatment 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 discharge instructions? Standard Text: Select all that apply. 1. Report any fever to the health care provider. 2. Report any purulent drainage to the health care 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. Correct Answer: 1, 2, 3, 5 Rationale 1: Fever is indicative of infection and should be reported to the health care provider. Rationale 2: Purulent drainage is indicative of infection and should be reported to the health care provider. Rationale 3: Sterile dressings should be used on the superficial partial-thickness burns where the skin is not intact. Rationale 4: Daily cleansing is sufficient, with only soap and water, not alcohol. Rationale 5: Topical agents may be ordered by the health care provider, and the patient should follow directions for applying to help prevent infection. Global Rationale: Fever and purulent drainage are indicative of infection and should be reported to the health care provider. Sterile dressings should be used on the superficial partial-thickness burns where the skin is not intact. Daily cleansing is sufficient, with only soap and water, not alcohol. Topical agents may be ordered by the health care provider and the patient should follow directions for applying to help prevent infection. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast the pathophysiology and interprofessional care of a minor burn and a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 439 Question 13 Type: MCSA A patient is being evaluated for severe burns to the torso and upper extremities, with 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 Correct Answer: 1 Rationale 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. Rationale 2: There is an increase in microvascular permeability at the burn site. Rationale 3: The osmotic pressure is increased, causing fluid accumulation. Rationale 4: There is a reduction of fluids in the extracellular body compartments. Global Rationale: 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. There is a reduction of fluids in the extracellular body compartments. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.2. Differentiate the manifestations and diagnostic tests of burns. Page Number: 440 Question 14 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Urine output is not greatest initially. Rationale 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. Rationale 4: Urine output will not be elevated initially. Global Rationale: 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. After the shock period passes, the patient will enter a period of diuresis, which begins between 24 and 36 hours after the burn injury. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 442 Question 15 Type: MCMA 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 results should the nurse expect for this patient? Standard Text: 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 Correct Answer: 1, 2 Rationale 1: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in a reduction in filtration rate. Rationale 2: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in an increase in specific gravity. Rationale 3: During this period, creatinine levels are increased. Rationale 4: During this period, BUN levels increase. Rationale 5: During this period, uric acid is increased. Global Rationale: During the initial phases of a burn injury, blood flow to the renal system is reduced, resulting in a reduction in GFR and an increase in specific gravity. During this period, BUN levels, creatinine, and uric acid are increased. Cognitive Level: Analyzing LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.2. Differentiate the manifestations and diagnostic tests of burns. Page Number: 442, 445 Question 16 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Hemoglobin levels are not elevated. Rationale 3: Hemoglobin levels are not elevated, and hematocrit levels are not decreased. Rationale 4: Hematocrit levels are not decreased. Global Rationale: 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.2. Differentiate the manifestations and diagnostic tests of burns. Page Number: 445 Question 17 Type: MCSA 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. Correct Answer: 1 Rationale 1: The heart rate in a burn-injured patient is not considered tachycardia until it reaches 120 beats per minute. Rationale 2: A heart rate of 112 in this patient does not indicate an infection. Rationale 3: A heart rate of 112 in this patient does not indicate an electrolyte imbalance. Rationale 4: A heart rate of 112 in this patient does not indicate renal failure. Global Rationale: The heart rate in a burn-injured patient is not considered tachycardia until it reaches 120 beats per minute. A heart rate of 112 in this patient does not indicate an infection, an electrolyte imbalance, or renal failure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.2. Differentiate the manifestations and diagnostic tests of burns. Page Number: 453 Question 18 Type: MCSA A patient has sustained a burn injury. Which nursing intervention is of the highest priority at this time? 1. determination of the type of burn injury 2. determination of the types of home remedies attempted prior to the patient’s coming to the hospital 3. assessment of past medical history 4. determination of body weight Correct Answer: 1 Rationale 1: Determination of the type of burn is the first step. The type of burn injury determines which nursing measures take priority. Rationale 2: The use of home remedies must be assessed, but it is not the highest priority. Rationale 3: Determining the past medical history is important, but it is not the highest priority. Rationale 4: The body weight must be determined, but it is not the highest priority. Global Rationale: Determination of the type of burn is the first step. The type of injury will dictate the interventions performed. Determining the use of home remedies, past medical history, and body weight must be completed, but are not of the highest priority. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 451 Question 19 Type: MCSA 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.” Correct Answer: 1 Rationale 1: The patient will begin to perform range-of-motion exercises after 5 days. Rationale 2: Itching is not a symptom of infection but an anticipated sign of cellular growth. Rationale 3: The ideal time to perform the procedure is early in the treatment of the burn injury. Rationale 4: The procedure is performed in a surgical suite. Global Rationale: The patient will begin to perform range-of-motion exercises after 5 days. Itching is not a symptom of infection but an anticipated sign of cellular growth. The ideal time to perform the procedure is early in the treatment of the burn injury. The procedure is performed in a surgical suite. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 448
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 20 Type: MCSA 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 Correct Answer: 1 Rationale 1: Morphine is preferred over meperidine for the burn-injured patient. 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. Rationale 2: Morphine is the drug of choice, but the preferred dose and route are different. Rationale 3: Meperidine is not the drug of choice for the burn-injured patient. Rationale 4: Meperidine is not the drug of choice for the burn-injured patient. Global Rationale: Morphine is preferred over meperidine for the burn-injured patient. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 445 Question 21 Type: MCMA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient with a burn injury is prescribed silver nitrate. Which nursing interventions should be included in the care for this patient? Standard Text: 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. Correct Answer: 1, 2, 5 Rationale 1: Silver nitrate can cause hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by daily weights. Rationale 2: Hyponatremia and hypochloremic alkalosis are common findings in patients treated with silver nitrate, so serum sodium and chloride should be monitored. Rationale 3: The dressings should be changed twice daily. Rationale 4: Black discolorations of the skin are anticipated in patients using silver nitrate and do not indicate a complication of therapy. Rationale 5: Silver nitrate in a 0.5% solution in distilled water should be applied to the dressings every 2 hours. Global Rationale: Silver nitrate can cause hypotonicity. Manifestations of hypotonicity include weight gain and edema, which can be monitored by daily weights. Hyponatremia and hypochloremic alkalosis are co mmon findings in patients treated with silver nitrate, so serum sodium and chloride should be monitored. Silver nitrate in a 0.5% solution in distilled water should be applied to the dressings every 2 hours. The dressings should be changed twice daily. Black discolorations of the skin are anticipated in patients using silver nitrate and do not indicate a complication of therapy. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 447 Question 22 Type: MCSA 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 Correct Answer: 1 Rationale 1: Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient’s nutritional plan. Rationale 2: Creatine phosphokinase is used to identify the presence of muscle injuries. Rationale 3: BUN levels are used to evaluate kidney function. Rationale 4: Hemoglobin levels fluctuate with the stages of the burn injury, depending on the fluid status. Global Rationale: Glucose in the urine is seen after a major burn injury. It signals the need to reevaluate the patient’s nutritional plan. Creatine phosphokinase is used to identify the presence of muscle injuries. BUN levels are used to evaluate kidney function. Hemoglobin levels fluctuate with the stages of the burn injury, depending on the fluid status. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 445 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 23 Type: MCMA A patient is beginning the acute phase of burn treatment. What priorities for care should the nurse anticipate for this patient? Standard Text: Select all that apply. 1. wound care 2. nutritional therapy 3. infection control 4. graft procedures 5. home maintenance management Correct Answer: 1, 2, 3 Rationale 1: During the acute stage, wound care management is initiated. Rationale 2: During the acute stage, nutritional therapies are initiated. Rationale 3: During the acute stage, measures to control infectious processes are initiated. Rationale 4: Graft procedures occur later in the healing process. Rationale 5: Home maintenance management is assessed during the rehabilitative stage, not the acute stage. Global Rationale: During the acute stage, wound care management, nutritional therapies, and measures to control infectious processes are initiated. Graft procedures occur later in the healing process. Assessment of home maintenance management is completed during the rehabilitative stage, not the acute stage. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 442 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Dextrose 5% with saline is not the solution of choice. Rationale 3: Dextrose 5% with water is not the solution of choice. Rationale 4: Normal saline is not the solution of choice. Global Rationale: Warmed 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. The other solutions are not the first choice in fluid resuscitation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 444
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 25 Type: FIB 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 Standard Text: Record your answer rounding to the nearest whole number. Correct Answer: 2,080 Rationale: 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 2,080 mL. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 444 Question 26 Type: MCHS Using the rule of nines, the nurse has estimated that the patient has sustained burns over 99% of the total body surface area (TBSA). Place an “X” on the portion of the body that is most likely unburned in this patient.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: The area most likely to be unburned in this patient is the perineum, which accounts for 1% of the body. This area is often unburned because of the protection of the trunk and the thighs. Global Rationale: LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Explain burn classification by depth and extent of injury. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 436 Question 27 Type: MCHS To stabilize the respiratory system of a patient injured in an explosion, the emergency department team must differentiate between upper airway thermal injury and lower airway toxic gas injury. Place an “X” on the structure that divides these two injury zones.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Injury above the glottis is upper airway injury and is generally related to inhalation of heated air or chemicals dissolved in water. Injury below the glottis is considered lower airway injury and is typically related to the effects of toxic gases rather than heat. Global Rationale: Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 441 Question 28 Type: MCHS A burn patient has developed abdominal pain, hematemesis, and melena. The nurse is concerned about the possible development of an ulcer. Place an “X” on the portion of the gastrointestinal tract where Curling ulcer develops.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Curling ulcer is a stress ulcer associated with burn injuries. These ulcers are located in the stomach or duodenum and are manifested by abdominal pain, acidic gastric pH levels, hematemesis, and melena. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.2. Differentiate the manifestations and diagnostic tests of burns. Page Number: 441 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 29 Type: MCHS The nurse is caring for a patient with a superficial partial-thickness burn. Place an “X” over the section of the diagram that represents the depth of this injury.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: A superficial partial-thickness burn damages the entire epidermis and the papillae of the dermis. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Explain burn classification by depth and extent of injury. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 434-435 Question 30 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Type: MCSA 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.” Correct Answer: 1 Rationale 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. Rationale 2: Asking the doctor to discuss the treatment plan does not answer the family’s question. Rationale 3: It is unlikely that the patient requested that the eschar be removed. Rationale 4: Scabs are not removed to check for blood flow. Global Rationale: 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. Asking the doctor to discuss the treatment plan does not answer the family’s question. It is unlikely that the patient requested that the eschar be removed. Scabs are not removed to check for blood flow. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 440 Question 31 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 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. Rationale 2: There is no evidence of a preexisting duodenal ulcer. Rationale 3: Although peristalsis is desired, it is not the primary gastrointestinal concern. Rationale 4: There is no data presented to indicate the presence of nausea or vomiting. Global Rationale: 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. There is no evidence of a preexisting duodenal ulcer and no mention of nausea or vomiting. Although peristalsis is desired, it is not the primary area of gastrointestinal concern. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Compare and contrast the pathophysiology and interprofessional care of a minor burn and a major burn. MNL Learning Outcome: 4.5.1. Examine the treatment options for burns. Page Number: 446 Question 32 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is caring for a patient with third-degree burns and notes a reduction in the serum potassium level. The nurse recognizes that this finding is consistent with which event? 1. the resolution of burn shock 2. the onset of burn shock 3. the onset of renal failure 4. the onset of liver failure Correct Answer: 1 Rationale 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. Rationale 2: Potassium levels are initially elevated at the onset of burn shock. Rationale 3: Reduced potassium levels are not indicators of the onset of renal failure. Rationale 4: Reduced potassium levels are not indicators of the onset of liver failure. Global Rationale: 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. Reduced potassium levels are not indicators of the onset of renal or liver failure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.1. Examine the treatment options for burns. Page Number: 445 Question 33 Type: MCSA A patient who is 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 1: Approximately 3%–5% of patients develop hypersensitivity to mafenide acetate, which can manifest as facial edema. Rationale 2: Facial and neck edema is considered an adverse reaction. Rationale 3: The information presented is inadequate to assess whether the dosage should be increased. Rationale 4: Facial and neck edema is a response to the medication. Global Rationale: Approximately 3%–5% of patients develop hypersensitivity to mafenide acetate, which can manifest as facial edema. Facial and neck edema is considered an adverse reaction. The information presented is inadequate to assess whether the dosage should be increased. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.1. Examine the treatment options for burns. Page Number: 447 Question 34 Type: MCSA Following surgical debridement, a patient with third-degree burns does not bleed. What does the nurse understand about this situation? 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. The patient should have an escharotomy instead. Correct Answer: 1 Rationale 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. Rationale 2: The procedure is still necessary. Rationale 3: It is an assumption that patients having debridement all require premedication. Rationale 4: An escharotomy involves removal of the hardened crust covering the burned area. Global Rationale: 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. It is an assumption that patients having debridement all require premedication. An escharotomy involves removal of the hardened crust covering the burned area. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.1. Examine the treatment options for burns. Page Number: 448 Question 35 Type: MCSA The nurse is providing care to a patient with a third-degree burn on the left thigh and left forearm. During wound care, the nurse applies Elase to the burned areas. Which type of wound debridement is this nurse using? 1. enzymatic 2. mechanical 3. surgical 4. topical Correct Answer: 1 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Mechanical debridement may be performed by applying and removing gauze dressings, hydrotherapy, irrigation, or using scissors and tweezers. Rationale 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. Rationale 4: Topical treatments are key in the care of a burn but do not involve debridement. Global Rationale: 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. Mechanical debridement may be performed by applying and removing gauze dressings, hydrotherapy, irrigation, or using scissors and tweezers. 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. Topical treatments are key in the care of a burn but do not involve debridement. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.1. Examine the treatment options for burns. Page Number: 449 Question 36 Type: MCSA A patient with third-degree 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. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
4. It is indicative of pending renal failure. Correct Answer: 1 Rationale 1: Intake and output measurements indicate the adequacy of fluid resuscitation and should range from 30 to 50 mL per hour in an adult. Rationale 2: A urine output of 40 mL/hr does not indicate dehydration. Rationale 3: A urine output of 40 mL/hr does not indicate overhydration. Rationale 4: A urine output of 40 mL/hr does not indicate pending renal failure. Global Rationale: Intake and output measurements indicate the adequacy of fluid resuscitation and should range from 30 to 50 mL per hour in an adult. A urine output of 40 mL/hr does not indicate dehydration, overhydration, or pending renal failure. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.1. Examine the treatment options for burns. Page Number: 453 Question 37 Type: MCSA 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. Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: Arm exercise is not related to the amount of urine in the catheter bag. Rationale 3: Linen changes do not impact range-of-motion activities. Rationale 4: The dressing is changed according to the physician’s orders or as needed. Global Rationale: The nurse should anticipate this patient’s needs for analgesia and administer pain medication to promote the patient’s comfort during the exercise session. Arm exercise is not related to the amount of urine in the catheter bag. Linen changes do not impact range-of-motion activities. The dressing is changed according to the physician’s orders or as needed. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.4. Utilize the nursing process in care of client. Page Number: 454 Question 38 Type: MCSA A patient with third-degree burns to the face has just learned 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 Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: The patient with a third-degree burn is at risk for infection; however, this question is focused on the impact of facial scarring. Rationale 3: There is inadequate information to determine the patient’s lack of body fluids. Rationale 4: There is inadequate information to determine changes in airway maintenance. Global Rationale: 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. The patient with a third-degree burn is at risk for infection; however, this question is focused on the impact of facial scarring. There is inadequate information to determine the patient’s lack of body fluids or changes in airway maintenance. Cognitive Level: Applying Client Need: Psychosocial Integrity Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.4. Utilize the nursing process in care of client. Page Number: 454 Question 39 Type: MCSA A patient comes to the clinic to be seen for a burn that appears moist with blisters. The nurse realizes that this patient most likely has sustained which type of burn? 1. superficial 2. superficial partial-thickness 3. deep partial-thickness 4. full thickness
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: 2 Rationale 1: A superficial burn would involve only the surface layer of skin. Redness would be expected. Rationale 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. Rationale 3: Deep partial-thickness burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. Rationale 4: Full-thickness burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. Global Rationale: 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. A superficial burn would involve only the surface layer of skin. Redness would be expected. Deep partial-thickness and full-thickness burns would be deeper and involve more damage to the dermis, epidermis, and underlying tissue. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Explain burn classification by depth and extent of injury. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 435 Question 40 Type: MCSA A patient comes to the clinic complaining of nausea and vomiting after spending the weekend at a seaside resort. What should be the most important assessment for the nurse? 1. whether the patient is resting and sleeping normally 2. whether the patient is following a typical meal pattern 3. whether the patient had to change time zones when traveling to the resort 4. whether the patient has been sunburned Correct Answer: 4 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: The patient has not reported concerns that would support issues with sleep pattern. Rationale 2: The patient has not reported concerns that would support issues with diet. Rationale 3: The patient has not reported concerns that would support issues with travel. Rationale 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. Global Rationale: Sunburns result 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. The patient did not report concerns that would support issues with sleep pattern, diet, and travel. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 1. Discuss the types and causative agents of burns. MNL Learning Outcome: 4.5.2. Differentiate the manifestations and diagnostic tests of burns. Page Number: 438 Question 41 Type: MCSA A patient comes to the physician’s office after sustaining chemical burns to the left side of the face and right wrist. Where does this patient need to be treated? 1. in the outpatient ambulatory clinic 2. in the emergency department 3. in a burn center 4. in the doctor’s office, and then at home Correct Answer: 3 Rationale 1: Patients with small or noninvasive burns may be managed at an outpatient clinic. Rationale 2: The emergency department is where a burn would be evaluated.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Rationale 4: The physician’s office can manage mild burns. Global Rationale: Adult patients who should be treated at burn centers include those with burns that involve the hands, feet, face, eyes, ears, or perineum. Patients with small or noninvasive burns may be managed at an outpatient clinic. The emergency department is where a burn would be evaluated. The physician’s office and the ambulatory clinic can manage mild burns. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 3. Compare and contrast the pathophysiology and interprofessional care of a minor burn and a major burn. MNL Learning Outcome: 4.5.3. Examine the treatment options for burns. Page Number: 442 Question 42 Type: MCMA During an assessment of a patient’s arm burn, the nurse notes an area of stasis. What changes should the nurse expect to assess in this area over the next week? Standard Text: 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. Correct Answer: 1, 2, 4 Rationale 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. Rationale 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. Rationale 3: The outer zone of hyperemia is unburned tissue and blanches on pressure. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 5: The inner zone of coagulation immediately appears leathery and coagulated. Global Rationale: The medial zone of stasis is initially moist, red, and blistered and blanches on pressure. It may recover or become pale and necrotic on days 3 to 7 postburn due to decreased perfusion or infection. The outer zone of hyperemia is unburned tissue and blanches on pressure. The inner zone of coagulation immediately appears leathery and coagulated. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 440 Question 43 Type: MCMA A victim of a fire in a clothing shop is complaining of headache and dizziness and has a potentially dangerous heart rhythm. What actions should the nurse expect to be performed for this patient? Standard Text: Select all that apply. 1. treatment with prednisone 2. treatment with vancomycin 3. treatment with hydroxocobalamin 4. hyperbaric oxygen therapy 5. pacemaker insertion Correct Answer: 3, 4 Rationale 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. Rationale 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. Rationale 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Rationale 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 high-pressure chamber) may be used with inhalation of smoke. Rationale 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. Global Rationale: 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 high-pressure chamber) may be used with inhalation of smoke. Hydroxocobalamin (Cyanokit) is a form of vitamin B12 that converts cyanide to a form that can be excreted from the body. Prednisone, vancomycin, and pacemaker insertion are not used to treat cyanide poisoning. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 4. Discuss the systemic pathophysiologic effects of a major burn and the stages of burn wound healing. MNL Learning Outcome: 4.5.1. Explain the risk factors, types, classification, and healing process of burns. Page Number: 441 Question 44 Type: MCMA 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? Standard Text: Select all that apply. 1. Check routinely for the odor of gas. 2. Suggest that no one smoke 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. Correct Answer: 1, 2, 5
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Actions to reduce the risk of a burn injury in the home include checking routinely for the odor of gas. Rationale 2: Actions to reduce the risk of a burn injury in the home include encouraging that no one smoke in the home. Rationale 3: Actions to reduce the risk of a burn injury in the home include wearing close-fitting, not loosefitting, clothing when cooking. Rationale 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. Rationale 5: Actions to reduce the risk of a burn injury in the home include keeping the hot water heater temperature at 120°F. Global Rationale: Actions to reduce the risk of a burn injury in the home include checking routinely for the odor of gas, encouraging that no one smoke in the home, and keeping the hot water heater temperature at 120°F. Closefitting clothing should be worn when cooking. Smoke detector batteries should be checked once a month. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.4. Utilize the nursing process in care of client. Page Number: 451 Question 45 Type: MCMA A patient recovering from a 30% TBSA full-thickness burn has swelling and inflammation of the intact skin around the burn area. What interventions should the nurse implement to reduce this patient’s risk of developing further infections? Standard Text: 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. Correct Answer: 1, 2, 3, 5 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 1: Interventions to reduce the risk of infection include reporting results of blood cultures so that antibiotic therapy can be initiated. Rationale 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. Rationale 3: Interventions to reduce the risk of infection include following strict isolation techniques to prevent the development of a nosocomial infection. Rationale 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. Rationale 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. Global Rationale: Interventions to reduce the risk of infection include reporting results of blood cultures so that antibiotic therapy can be initiated, monitoring leukocyte counts as indicators of immune system function, following strict isolation techniques to prevent the development of a nosocomial infection, and discussing the patient’s nutritional needs with the dietician. The use of an indwelling catheter should be reduced or eliminated because of the high risk of urinary tract infection. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Explain the interprofessional care and nursing implications necessary during the emergent/resuscitative stage, the acute stage, and the rehabilitative stage of a major burn. MNL Learning Outcome: 4.5.4. Utilize the nursing process in care of client. Page Number: 453
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 18
Question 1 Type: MCSA 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?” Correct Answer: 1 Rationale 1: The patient experiencing hypothyroidism has rough, dry skin. Rationale 2: Smooth, flushed skin is associated with hyperthyroidism. Rationale 3: Cool, clammy skin is found in patients with low blood sugar. Rationale 4: Brown, shiny patches on the lower extremities are associated with poor circulation. Global Rationale: The patient experiencing hypothyroidism has rough, dry skin. Smooth, flushed skin is associated with hyperthyroidism. Cool, clammy skin is found in patients with low blood sugar. Brown shiny patches on the lower extremities are associated with poor circulation. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 3. Describe specific topics to consider during a health history interview of the patient with health problems involving endocrine function. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 472
Question 2 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Chvostek sign is elicited by tapping on the face in front of the ear and observing for contractions of the facial muscle. Rationale 3: Turner sign is observed on a patient’s abdomen and flank and associated with intra- or retroperitoneal bleeding. Rationale 4: Cullen signs is observed on a patient’s abdomen and flank and associated with intra- or retroperitoneal bleeding Global Rationale: 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. Chvostek sign is elicited by tapping on the face in front of the ear and observing for contractions of the facial muscle. Turner and Cullen signs are observed on a patient’s abdomen and flank and are associated with intra- or retroperitoneal bleeding. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 473
Question 3 Type: MCSA A patient has a positive Trousseau sign. For which problem should the nurse plan care for this patient? 1. pain 2. excessive fluid 3. difficulty breathing 4. reduced blood flow Correct Answer: 1 Rationale 1: A positive Trousseau sign causes painful carpal spasms due to decreased calcium. The patient will be experiencing pain. Rationale 2: A positive Trousseau sign is not associated with fluid volume. Rationale 3: A positive Trousseau sign is not associated with respiratory function. Rationale 4: A positive Trousseau sign is not associated with perfusion or blood flow. Global Rationale: A positive Trousseau sign causes painful carpal spasms due to decreased calcium. The patient will be experiencing pain. A positive Trousseau sign is not associated with fluid volume, respiratory function, or perfusion or blood flow. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 8. 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: Planning Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 473
Question 4 Type: MCMA During an endocrine assessment, the nurse asks a patient about changes in weight. For which organs is the nurse assessing function in the patient? Standard Text: Select all that apply. 1. adrenal 2. thyroid 3. pituitary 4. parathyroid 5. gonads Correct Answer: 1, 2, 3 Rationale 1: Disorders of the adrenal glands can result in weight changes by altering fluid balance. Rationale 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. Rationale 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. Rationale 4: The parathyroid gland regulates calcium and phosphorous. Rationale 5: The gonads influence estrogen and androgens.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Disorders of the adrenal, thyroid, and pituitary glands can result in weight changes in patients with disorders of these glands. The patient might gain weight with an adrenal disorder because of fluid retention, or with thyroid disease, such as hypothyroidism. The patient may lose weight with hyperthyroidism. The pituitary gland controls antidiuretic hormone, which influences the renal tubules to absorb water. The parathyroid gland regulates calcium and phosphorous, whereas the gonads influence estrogen and androgens. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe specific topics to consider during a health history interview of the patient with health problems involving endocrine function. MNL Learning Outcome: 10.3.2. Differentiate the manifestations of adrenal gland disorders. Page Number: 463-464
Question 5 Type: MCSA The nurse is assessing a patient with a pituitary disorder. Which finding does the nurse assess for 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 Correct Answer: 1 Rationale 1: In a patient experiencing a pituitary disorder such as acromegaly, enlargement of the hands and feet may be observed. Rationale 2: Thin, soft hair occurs in hyperthyroidism. Rationale 3: Hirsutism is associated with Cushing disease, an adrenal disorder. Rationale 4: Purple striae are associated with Cushing disease, an adrenal disorder. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: In a patient experiencing a pituitary disorder such as acromegaly, enlargement of the hands and feet may be observed. Thin, soft hair occurs in hyperthyroidism; hirsutism and purple striae are associated with Cushing disease, an adrenal disorder. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.4.2. Differentiate the manifestations of pituitary gland disorders. Page Number: 473
Question 6 Type: MCSA 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 Correct Answer: 1 Rationale 1: Exophthalmos is a clinical manifestation associated with hyperthyroidism. Rationale 2: Dry, thick nails are associated with hypothyroidism. Rationale 3: Dry skin is associated with hypothyroidism. Rationale 4: Decreased reflexes are associated with hypothyroidism. Global Rationale: Exophthalmos is a clinical manifestation associated with hyperthyroidism. Dry, thick nails; dry skin; and decreased reflexes are associated with hypothyroidism. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 472
Question 7 Type: MCSA 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 Correct Answer: 1 Rationale 1: Dwarfism results from insufficient growth hormone produced by the pituitary gland. Rationale 2: Carpal spasms can indicate a parathyroid gland disorder. Rationale 3: An enlarged thyroid nodule could be associated with a thyroid malignancy. Rationale 4: Hyperpigmentation of the skin might be associated with an adrenal disorder such as Addison disease or Cushing syndrome. Global Rationale: Dwarfism results from insufficient growth hormone produced by the pituitary gland. Carpal spasms can indicate a parathyroid gland disorder. An enlarged thyroid nodule could be associated with a thyroid malignancy. Hyperpigmentation of the skin might be associated with an adrenal disorder such as Addison disease or Cushing syndrome. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.4.2. Differentiate the manifestations of pituitary gland disorders. Page Number: 473
Question 8 Type: MCSA The nurse is caring for a patient with Graves disease. On which laboratory value should the nurse focus for this patient? 1. thyroxine 2. urine-specific gravity 3. cortisol 4. calcium Correct Answer: 1 Rationale 1: Thyroxine (T4) is the hormone secreted by the thyroid gland. Thyroxine (T4) is converted to triiodothyronine (T3), and both are secreted in response to thyroid-stimulating hormone (TSH). Rationale 2: Urine-specific gravity would be measured to provide information about the posterior pituitary. Rationale 3: The adrenal gland produces cortisol. Rationale 4: The parathyroid gland regulates calcium and phosphorous. Global Rationale: Thyroxine (T4) is the hormone secreted by the thyroid gland. Thyroxine (T4) is converted to triiodothyronine (T3), and both are secreted in response to thyroid-stimulating hormone (TSH). Urine-specific gravity would be measured to provide information about the posterior pituitary. The adrenal gland produces cortisol. The parathyroid gland regulates calcium and phosphorous. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the thyroid gland and the effects of altered function of thyroid hormones. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 462-463
Question 9 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: The thyroid gland is not palpated by standing in front of the patient. Rationale 3: Placing the patient supine would not permit the nurse to have full access to the neck. Rationale 4: Flexing the neck forward could occlude the airway if a mass were present. Global Rationale: 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. The nurse has better access to the thyroid from a posterior approach than from the LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
anterior aspect. Placing the patient supine would not permit the nurse to have full access to the neck. Flexing the neck forward could occlude the airway if a mass were present. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the thyroid gland and the effects of altered function of thyroid hormones. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 472
Question 10 Type: MCMA The nurse is beginning the assessment of a patient with an endocrine disorder. What should the nurse include in this assessment? Standard Text: Select all that apply. 1. height and weight 2. skin, hair, and nails 3. deep tendon reflexes 4. musculoskeletal system 5. respiratory system Correct Answer: 1, 2, 3, 4 Rationale 1: When assessing a patient’s endocrine system, the nurse should include measuring height and weight. Rationale 2: When assessing a patient’s endocrine system, the nurse should include evaluating skin, hair, and nails. Rationale 3: When assessing a patient’s endocrine system, the nurse should include evaluating reflexes. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: When assessing a patient’s endocrine system, the nurse should include evaluating the musculoskeletal system. Rationale 5: The respiratory system does not influence the endocrine system. Global Rationale: When assessing a patient’s endocrine system, the nurse should include measuring height and weight, and evaluating skin, hair, nails, reflexes, and the musculoskeletal system. The respiratory system does not influence the endocrine system. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe specific topics to consider during a health history interview of the patient with health problems involving endocrine function. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 471-472
Question 11 Type: MCSA 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 Correct Answer: 1 Rationale 1: Decreased sensitivity to insulin and delayed and decreased insulin release are seen in the older patient diagnosed with type 2 diabetes. Rationale 2: Delayed and decreased insulin release are seen in the older patient diagnosed with type 2 diabetes. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: Intolerance of fatty foods occurs in older adults but is not specific to the older patient with type 2 diabetes. Rationale 4: Blood glucose levels are higher and prolonged in the older patient with diabetes. Global Rationale: Decreased sensitivity to insulin and delayed and decreased insulin release are seen in the older patient diagnosed with type 2 diabetes. Intolerance of fatty foods occurs in older adults but is not specific to the older patient with type 2 diabetes. Blood glucose levels are higher and prolonged in the older patient with diabetes. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 5. Describe normal variations in endocrine assessment findings for the older adult. MNL Learning Outcome: 10.5.1. Explain the incidence, prevalence, and pathophysiology for diabetes. Page Number: 471
Question 12 Type: MCSA 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.” Correct Answer: 1 Rationale 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. Rationale 2: There are no food or fluid restrictions. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: The 17-ketosteroid test is a 24-hour collection of urine to evaluate adrenal cortex function. Rationale 4: The test does not include having blood drawn. Global Rationale: 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. There are no food or fluid restrictions and the test does not include having blood drawn. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Summarize the functions of the hormones secreted by the endocrine glands. MNL Learning Outcome: 10.3.3. Examine the diagnosis and treatment of adrenal gland disorders. Page Number: 469
Question 13 Type: MCMA The nurse is conducting a health assessment interview with a patient. What should the nurse include when assessing the patient’s endocrine system? Standard Text: 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 Correct Answer: 1, 2, 3, 4 Rationale 1: During assessment of the endocrine system, the nurse should ascertain data about occupation. Rationale 2: During assessment of the endocrine system, the nurse should ascertain data about substance use. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 3: During assessment of the endocrine system, the nurse should ascertain data about lifestyle and personal relationships. Rationale 4: During assessment of the endocrine system, the nurse should ascertain data about exercise and sleep patterns. Rationale 5: Bowel habits are not influenced by the endocrine system. Global Rationale: During assessment of the endocrine system, the nurse should ascertain data about occupation, substance use, lifestyle, personal relationships, exercise, and sleep patterns. Bowel habits are not influenced by the endocrine system. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe specific topics to consider during a health history interview of the patient with health problems involving endocrine function. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 471
Question 14 Type: MCSA The nurse is conducting a health interview with a female patient. What should the nurse ask this patient 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?” Correct Answer: 1 Rationale 1: The patient who has a change in her menstrual cycle might be experiencing an endocrine disorder such as increased androgen production or decreased estrogen levels. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: Having children is not a function of the endocrine system. Rationale 3: Asking how the patient is able to provide for her children provides psychosocial information. Rationale 4: Asking when menses first began might provide information about cancer risk but not about endocrine function. Global Rationale: The patient who has a change in her menstrual cycle might be experiencing an endocrine disorder such as increased androgen production or decreased estrogen levels. Having children is not a function of the endocrine system. Asking how the patient is able to provide for her children provides psychosocial information. Asking when menses first began might provide information about cancer risk but not about endocrine function. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 3. Describe specific topics to consider during a health history interview of the patient with health problems involving endocrine function. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 471
Question 15 Type: MCSA A patient is experiencing severe hypertension. The nurse realizes that this finding might indicate a disorder in which endocrine gland? 1. adrenal 2. thyroid 3. parathyroid 4. gonads Correct Answer: 1
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 2: The thyroid regulates metabolism. Rationale 3: The parathyroid gland regulates calcium. Rationale 4: The gonads secrete the hormones of sexuality. Global Rationale: 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. The thyroid regulates metabolism. The parathyroid gland regulates calcium. The gonads secrete the hormones of sexuality. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the anatomy and physiology of the endocrine glands. MNL Learning Outcome: 10.3.2. Differentiate the manifestations of adrenal gland disorders. Page Number: 464
Question 16 Type: MCHS The nurse is conducting a physical assessment with a patient. Using the diagram (see below), place an “X” over the location on the body where the nurse would assess for Chvostek sign.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Chvostek sign is elicited by using a finger to tap in front of the patient’s ear at the angle of the jaw. This sign indicates hypocalcemia associated with hypoparathyroidism. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.2.4. Utilize the nursing process in care of client. Page Number: 473
Question 17 Type: MCSA An older adult patient tells the nurse she is ingesting a fat-soluble vitamin every day to boost her 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. Correct Answer: 1 Rationale 1: Absorption of fat-soluble vitamins declines with age. Rationale 2: Lipase production decreases in the older adult patient, causing reduced fat absorption. Rationale 3: Older patients have increased resistance to insulin, but this has no effect on absorption of fat-soluble vitamins. Rationale 4: Lipase production decreases in the older adult patient, causing reduced fat absorption. This may result in intolerance to fatty foods and indigestion. Global Rationale: Absorption of fat-soluble vitamins declines with age. Lipase production decreases in the older adult patient, causing reduced fat absorption. This may result in intolerance to fatty foods and indigestion. Older patients have increased resistance to insulin, but this has no effect on absorption of fat-soluble vitamins. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Evaluation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Describe normal variations in endocrine assessment findings for the older adult. MNL Learning Outcome: 11.7.4. Utilize the nursing process in care of client. Page Number: 471
Question 18 Type: MCMA The nurse is assessing an older patient for genetic influences on the endocrine system. What should the nurse ask this patient during the assessment? Standard Text: 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?” Correct Answer: 1, 2, 3 Rationale 1: A family history of diabetes mellitus has a genetic influence on the endocrine system. Rationale 2: Obesity has a genetic influence on the endocrine system. Rationale 3: Hashimoto disease has a genetic influence on the endocrine system. Rationale 4: Questions about the patient’s ability to cope with stress are asked to identify possible disorders of endocrine gland function. Rationale 5: Questions about changes in skin color are asked to identify possible disorders of endocrine gland function. Global Rationale: A family history of diabetes mellitus, obesity, and Hashimoto disease has a genetic influence on the endocrine system. Questions about the patient’s ability to cope with stress and changes in skin color are asked to identify possible disorders of endocrine gland function. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 6. Give examples of genetic disorders of the endocrine glands. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 470
Question 19 Type: MCSA During a focused endocrine assessment, the patient states that her brother has fragile X syndrome. What should the nurse know 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. Correct Answer: 1 Rationale 1: Fragile X syndrome involves a gene mutation causing learning disabilities and mental retardation and is considered an endocrine disorder. Rationale 2: Males are more severely affected than females, and both sexes can be carriers of the disorder. Rationale 3: Fragile X syndrome is considered an endocrine disorder. Rationale 4: Fragile X syndrome is not a blood disorder. Global Rationale: Fragile X syndrome involves a gene mutation causing learning disabilities and mental retardation and is considered an endocrine disorder. Males are more severely affected than females and both sexes can be carriers of the disorder. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 6. Give examples of genetic disorders of the endocrine glands. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 470
Question 20 Type: MCMA A patient is scheduled for surgery to remove a tumor of the anterior pituitary. The nurse realizes that which hormones will be affected by this surgery? Standard Text: Select all that apply. 1. adrenocorticotropic hormone (ACTH) 2. thyroid stimulating hormone (TSH) 3. gonadotropin hormones 4. prolactin 5. oxytocin Correct Answer: 1,2,3,4 Rationale 1: The anterior pituitary produces adrenocorticotropic hormone. Rationale 2: The anterior pituitary produces thyroid-stimulating hormone. Rationale 3: The anterior pituitary produces the gonadotropin hormones, one of which is follicle-stimulating. Rationale 4: The anterior pituitary produces the gonadotropin hormones, one of which is prolactin. Rationale 5: Oxytocin is produced in the posterior pituitary. Global Rationale: The anterior pituitary produces adrenocorticotropic hormone, thyroid-stimulating hormone, the gonadotropin hormones which are follicle stimulating hormone and luteinizing hormone, growth hormone, and prolactin. Oxytocin is produced in the posterior pituitary. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 2. Summarize the functions of the hormones secreted by the endocrine glands. MNL Learning Outcome: 10.4.3. Examine the diagnosis and treatment of pituitary gland disorders. Page Number: 462-463
Question 21 Type: MCSA 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. The nurse is explaining what route of hormone transport in the body? 1. paracrine method 2. direct release into the bloodstream 3. neuroendocrine route 4. nerve cell extension into the posterior pituitary Correct Answer: 1 Rationale 1: The paracrine method involves diffusion of hormones through interstitial fluids to act locally. Endorphins produce pain relief in this manner. Rationale 2: This method does not release hormones directly into the bloodstream. Rationale 3: This method is not the neuroendocrine route. Rationale 4: This method is not accomplished through nerve cell extension into the posterior pituitary. Global Rationale: The paracrine method involves diffusion of hormones through interstitial fluids to act locally. Endorphins produce pain relief in this manner. The paracrine method does not release hormones directly into the blood stream, through the neuroendocrine route, or through cell extension into the posterior pituitary. Cognitive Level: Applying Client Need: Health Promotion and Maintenance LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Summarize the functions of the hormones secreted by the endocrine glands. MNL Learning Outcome: 10.4.3. Examine the diagnosis and treatment of pituitary gland disorders. Page Number: 465
Question 22 Type: MCSA 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 Correct Answer: 1 Rationale 1: A lowered basal metabolic rate due to decreased thyroid activity in the aging patient may cause intolerance to heat and cold. Rationale 2: Decreased production of the pancreatic enzyme lipase results in indigestion and intolerance of fatty foods. Rationale 3: Increased facial hair occurs with decreased pituitary function. Rationale 4: Enlargement of nose, hands, and feet occurs with decreased pituitary function. Global Rationale: A lowered basal metabolic rate due to decreased thyroid activity in the aging patient may cause intolerance to heat and cold. Decreased production of the pancreatic enzyme lipase results in indigestion and intolerance of fatty foods. Increased facial hair and enlargement of the nose, hands, and feet occur due to decreased pituitary function. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 5. Describe normal variations in endocrine assessment findings for the older adult. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 471
Question 23 Type: MCSA The nurse is instructing a patient with low levels of circulating thyroid hormone. The nurse should encourage the patient to increase foods containing which nutrient? 1. iodine 2. calcium 3. phosphorus 4. vitamin D Correct Answer: 1 Rationale 1: Iodine is necessary for adequate thyroid hormone secretion. Rationale 2: Calcium does not affect thyroid hormone secretion. Rationale 3: Phosphorus does not affect thyroid hormone secretion. Rationale 4: Vitamin D does not affect thyroid hormone secretion. Global Rationale: Iodine is necessary for adequate thyroid hormone secretion. Calcium, phosphorus, and vitamin D do not affect thyroid hormone secretion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Summarize the functions of the hormones secreted by the endocrine glands. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 463
Question 24 Type: MCMA The nurse is conducting an interview with an adult female patient. Which questions should the nurse ask that focus on genetic factors that influence the endocrine system? Standard Text: 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? Correct Answer: 1, 2, 3 Rationale 1: Questions for the female patient that could identify genetic factors affecting the patient would include problems with pregnancy. Rationale 2: Questions for the female patient that could identify genetic factors affecting the patient would include problems with menstruation. Rationale 3: Questions for the female patient which could identify genetic factors affecting the patient would include problems with menopause. Rationale 4: This question does not focus on possible genetic influences on endocrine function. Rationale 5: This question does not focus on possible genetic influences on endocrine function.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Questions for the female patient that could identify genetic factors affecting the patient would focus on problems with menstruation, pregnancy, and/or menopause. The other responses are appropriate for assessing endocrine function but do not focus on possible genetic influences. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 6. Give examples of genetic disorders of the endocrine glands. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 470
Question 25 Type: MCSA A patient is demonstrating symptoms of dehydration and excessive urination. The nurse realizes the patient might be experiencing an alteration in what hormone? 1. antidiuretic hormone (ADH) 2. adrenocorticotropic hormone (ACTH) 3. follicle-stimulating hormone (FSH) 4. thyroid-stimulating hormone (TSH) Correct Answer: 1 Rationale 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. Rationale 2: Adrenocorticotropic hormone stimulates adrenal function. Rationale 3: Follicle-stimulating hormone functions in ovum and sperm formation. Rationale 4: Thyroid-stimulating hormone stimulates thyroid function.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Follicle-stimulating hormone functions in ovum and sperm formation. Adrenocorticotropic hormone stimulates adrenal function. Thyroid-stimulating hormone stimulates thyroid function. Alteration in these hormones does not have as direct of a relationship to the patient’s symptoms as antidiuretic hormone does. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the anatomy and physiology of the endocrine glands. MNL Learning Outcome: 10.3.1. Explain the causes, risk factors, incidence, and pathophysiology of adrenal gland disorders. Page Number: 463
Question 26 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: The paracrine route involves endorphins being released into interstitial fluids to act locally in response to inflammation.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 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. Rationale 4: The hypothalamus releases its hormones directly to target cells in the posterior pituitary by nerve cell extension. Global Rationale: 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. The paracrine route involves endorphins being released into interstitial fluids to act locally in response to inflammation. 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. The hypothalamus releases its hormones directly to target cells in the posterior pituitary by nerve cell extension. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 1. Describe the anatomy and physiology of the endocrine glands. MNL Learning Outcome: 10.3.1. Explain the causes, risk factors, incidence, and pathophysiology of adrenal gland disorders. Page Number: 464-465
Question 27 Type: MCHS Place an “X” over the site of the site on the body where a nurse would assess stereognosis.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: Stereognosis is assessed by placing a simple or familiar object, such as a rubber band or key, in the palm of the patient’s hand and asking the patient to identify the object. This technique assesses sensory function. Global Rationale: Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 1. Describe the anatomy and physiology of the endocrine glands. MNL Learning Outcome: 10.3.1. Explain the causes, risk factors, incidence, and pathophysiology of adrenal gland disorders. Page Number: 473
Question 28 Type: SEQ The nurse is assessing a patient for Trousseau sign. In which order should the nurse conduct this assessment? Standard Text: Click and drag the options below to move them up or down. 1. Inflate the cuff. 2. Wait 2‒5 minutes. 3. Note a point greater than systolic blood pressure. 4. Place a blood pressure cuff above the antecubital space. 5. Observe for carpal spasms in the patient’s hands and fingers. Correct Answer: 4, 1, 3, 2, 5 Rationale 1: Inflate the cuff to a point greater than systolic blood pressure. Rationale 2: Wait for 2‒5 minutes. Rationale 3: Inflate the cuff to a point greater than systolic blood pressure. Rationale 4: 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. Rationale 5: Observe for carpal spasms in the patient’s hands and fingers Global Rationale: 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. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.2.4. Utilize the nursing process in care of client. Page Number: 473
Question 29 Type: MCSA The results of a patient’s oral glucose tolerance test are reviewed by the nurse. How should the nurse interpret these results?
1. Results are within normal range. 2. The patient should be evaluated for diabetes mellitus. 3. The findings indicate hyperinsulinism. 4. The results are inconsistent; therefore, the test will need to be repeated. Correct Answer: 1 Rationale 1: Values for 2-h plasma at 139 or below are considered normal. Rationale 2: The results are normal, so there is no indication for further evaluation or testing. Rationale 3: There is no indication of hyperinsulinism.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 4: These results are not inconsistent, and the test does not need to be repeated. Global Rationale: Values for 2-h plasma at 139 or below are considered normal. There is no indication of diabetes mellitus, hyperinsulinism or inconsistency indicating the need for further evaluation or testing. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.5.3. Examine the diagnosis, monitoring, treatment options, and complications for diabetes. Page Number: 470
Question 30 Type: MCSA When reviewing the patient’s record, the nurse sees the results of a recent blood chemistry profile. These results indicate the patient is being evaluated for what health problem?
1. hyperparathyroidism 2. Cushing syndrome 3. thyroiditis 4. hypothyroidism Correct Answer: 1 Rationale 1: Parathyroid hormone (PTH) affects calcium and phosphate metabolism. Normal levels of vitamin D are necessary for PTH to exert its effects. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 2: The blood chemistry profile is not indicative of a patient with Cushing syndrome. Rationale 3: The blood chemistry profile is not indicative of a patient with thyroiditis. Rationale 4: The blood chemistry profile is not indicative of a patient with hypothyroidism. Global Rationale: Parathyroid hormone (PTH) affects calcium and phosphate metabolism. Normal levels of vitamin D are necessary for PTH to exert its effects. The blood chemistry profile is not indicative of a patient with Cushing syndrome, thyroiditis or hypothyroidism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.2.3. Examine the diagnosis and treatment of parathyroid disorders. Page Number: 463
Question 31 Type: MCHS The nurse is conducting a physical assessment on a patient. Place an “X” over the location on the body where the nurse should observe and/or palpate for a goiter.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Correct Answer: Rationale: A goiter is an enlarged thyroid gland, which would be palpated or observed on the anterior aspect of the neck. Global Rationale: Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the thyroid gland and the effects of altered function of thyroid hormones. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 472
Question 32 Type: MCSA A female patient comes into the clinic to be seen for fatigue and a cold that “won’t go away,” both of which began when she started a new job and her mother moved in with her family. The nurse realizes that this patient might be experiencing what reaction? 1. an increase in glucocorticoid secretion LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
2. an increase in epinephrine secretion 3. a drop in mineralocorticoid secretion 4. a reduction in norepinephrine secretion Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. Alteration in epinephrine, norepinephrine, or 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. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 5. Describe normal variations in endocrine assessment findings for the older adult. MNL Learning Outcome: 10.3.2. Differentiate the manifestations of adrenal gland disorders. Page Number: 464
Question 33 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
A patient who is scheduled to have a hemoglobin A1C level drawn asks the nurse 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.” Correct Answer: 1 Rationale 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. Rationale 2: Hemoglobin A1C does not measure kidney function. Rationale 3: Hemoglobin A1C does not measure thyroid function. Rationale 4: Hemoglobin A1C does not menopausal symptoms. Global Rationale: 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. Hemoglobin A1C does not measure kidney or thyroid function, nor does it evaluate menopausal symptoms. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.5.3. Examine the diagnosis, monitoring, treatment options, and complications for diabetes. Page Number: 470
Question 34 Type: MCSA LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
The nurse is planning to conduct a physical assessment of 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 Correct Answer: 1 Rationale 1: The only endocrine organ that can be palpated is the thyroid gland. Rationale 2: The anatomical location of the pancreas prohibits direct examination by palpation or percussion. Rationale 3: The anatomical location of the adrenal glands prohibits direct examination by palpation or percussion. Rationale 4: The anatomical location of the parathyroid glands prohibits direct examination by palpation or percussion Global Rationale: The only endocrine organ that can be palpated is the thyroid gland. The anatomical location of the pancreas, adrenal glands, and the parathyroid glands prohibits direct examination by palpation or percussion. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 4. Explain techniques for assessing the thyroid gland and the effects of altered function of thyroid hormones. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 471
Question 35 Type: MCSA
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
During an assessment the nurse notes that the patient’s eyes are extremely wide open and bulging. The nurse realizes that this finding is consistent with what health problem? 1. hyperthyroidism 2. diabetes mellitus 3. hypofunction of the adrenal glands 4. hypofunction of the anterior pituitary gland Correct Answer: 1 Rationale 1: Exophthalmos, or protruding eyes, may be seen in hyperthyroidism. Rationale 2: This is not a finding that is associated with diabetes mellitus. Rationale 3: This is not a finding that is associated with hypofunction of the adrenal glands. Rationale 4: This is not a finding that is associated with hypofunction of the pituitary gland. Global Rationale: Exophthalmos, or protruding eyes, may be seen in hyperthyroidism. This is not a finding that is associated with diabetes mellitus, hypofunction of the adrenal glands, or hypofunction of the pituitary gland. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 472
Question 36 Type: MCSA The nurse realizes an alteration in growth hormone can lead to changes in an individual’s physical stature. What condition should the nurse suspect is being caused by abnormally high levels of growth hormone in a patient? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
1. acromegaly 2. dwarfism 3. hirsutism 4. gynecomastia Correct Answer: 1 Rationale 1: Extremely large bones may indicate acromegaly, which is caused by excessive growth hormone. Rationale 2: Extremely short stature may indicate dwarfism, which is caused by insufficient growth hormone. Rationale 3: Hirsutism, or abnormal hair growth, is associated with adrenal hormone access. Rationale 4: Gynecomastia, or development of breast tissue in men, is frequently associated with androgen therapy. Global Rationale: Extremely large bones may indicate acromegaly, which is caused by excessive growth hormone. Extremely short stature may indicate dwarfism, which is caused by insufficient growth hormone. Hirsutism, or abnormal hair growth, is associated with adrenal hormone access. Gynecomastia, or development of breast tissue in men, is frequently associated with androgen therapy. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: Diagnosis Learning Outcome: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.4.2. Differentiate the manifestations of pituitary gland disorders. Page Number: 472
Question 37 Type: MCSA A patient comes into the clinic demonstrating symptoms of hypocalcemic tetany. What assessment should the nurse conduct to determine the patient’s condition? LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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. Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: Blood pressure measurement may give the nurse valuable information about the patient’s fluid and electrolyte status, but it does not evaluate tetany. Rationale 4: A capillary blood level for serum calcium would give a measurement, but it does not assess for the clinical symptoms of tetany. Global Rationale: 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. 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. Blood pressure measurement may give the nurse valuable information about the patient’s fluid and electrolyte status, but it does not evaluate tetany. A capillary blood level for serum calcium would give a measurement, but it does not assess for the clinical symptoms of tetany. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 473 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 38 Type: MCSA 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 Correct Answer: 1 Rationale 1: Older patients’ thyroid glands can be more fibrotic and nodular as a normal finding. Rationale 2: Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of hypertension. Rationale 3: Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of diabetes mellitus. Rationale 4: Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of reduction in urine output. Global Rationale: Older patients’ thyroid glands can be more fibrotic and nodular as a normal finding. Without other assessments or supporting data, a palpable thyroid gland does not explain the onset of hypertension, diabetes mellitus, or reduction in urine output. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 5. Describe normal variations in endocrine assessment findings for the older adult. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 471 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 39 Type: MCSA 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. indicative of pending parathyroid hormone disease Correct Answer: 1 Rationale 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. Rationale 2: Medication for a seizure disorder will not falsely elevate T3 and T4 blood levels. Rationale 3: T3 and T4 levels will not be normal when a patient is taking an antiseizure medication. Rationale 4: Measurement of T3 and T4 levels is not indicative of parathyroid disease. Global Rationale: 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. The levels will not be normal or increased. Measurement of T3 and T4 levels is not indicative of parathyroid disease. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the thyroid gland and the effects of altered function of thyroid hormones. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 467
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 40 Type: MCSA A middle-aged female patient is found to have a decrease in her cortisol level. The nurse realizes that this finding is consistent with what health problem? 1. Addison disease 2. hyperthyroidism 3. Cushing syndrome 4. nothing Correct Answer: 1 Rationale 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 consistent with Addison disease. Rationale 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. Rationale 3: Cushing syndrome would reveal an elevated cortisol level. Rationale 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 indicate a health problem. Global Rationale: 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 consistent with Addison disease and hypothyroidism. Cushing syndrome would reveal an elevated cortisol level. Decreased levels are not normal and do not indicate hyperthyroidism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. MNL Learning Outcome: 10.3.3. Examine the diagnosis and treatment of adrenal gland disorders. Page Number: 469 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Question 41 Type: MCSA After the most recent physician’s office visit and blood work, the patient learns that an oral glucose tolerance test scheduled for the next week is not needed. The patient says to the nurse, “This is good news if I don’t need additional testing.” What should the nurse recognize that the cancellation of this test indicates? 1. consistently high fasting blood glucose levels 2. no evidence of type 1 diabetes mellitus 3. normal renal functioning 4. normal liver functioning Correct Answer: 1 Rationale 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. Rationale 2: Cancellation of the test does not indicate absence of evidence of type 1 diabetes. Rationale 3: Cancellation of the test does not indicate normal liver function. Rationale 4: Cancellation of the test does not indicate normal renal function. Global Rationale: 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. Cancellation of the test does not indicate absence of evidence of type 1 diabetes, or normal liver or renal function. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 10.5.3. Examine the diagnosis, monitoring, treatment options, and complications for diabetes. Page Number: 470
Question 42 Type: MCMA 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? Standard Text: Select all that apply. 1. heart rate 112 2. cold extremities 3. respiratory rate 24 4. urine output 10 mL/hr 5. blood glucose level 142 mg/dL Correct Answer: 1, 2, 3, 5 Rationale 1: Hormones secreted by the adrenal medulla stimulate the heart. Rationale 2: Hormones secreted by the adrenal medulla constrict blood vessels, which could cause cold extremities. Rationale 3: Hormones secreted by the adrenal medulla can increase respirations. Rationale 4: Hormones secreted by the adrenal medulla do not affect urine output. Rationale 5: Hormones secreted by the adrenal medulla increase blood glucose. Global Rationale: Hormones secreted by the adrenal medulla stimulate the heart, constrict blood vessels, increase respirations, and increase blood glucose. Hormones secreted by the adrenal medulla do not affect urine output. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 7. Identify abnormal findings that may indicate malfunction of the glands of the endocrine system. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
MNL Learning Outcome: 10.3.2. Differentiate the manifestations of adrenal gland disorders. Page Number: 462
Question 43 Type: MCMA 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 types should the nurse focus? Standard Text: Select all that apply. 1. f cells 2. beta cells 3. delta cells 4. alpha cells 5. omega cells Correct Answer: 2, 3, 4 Rationale 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. Rationale 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. Rationale 3: Delta cells secrete somatostatin, which inhibits the secretion of glucagon and insulin by the alpha and beta cells. Rationale 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. Rationale 5: The pancreas does not have omega cells. Global Rationale: 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. Delta cells secrete somatostatin, which inhibits the secretion of glucagon and insulin by the alpha and beta cells. 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. 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. The pancreas does not have omega cells. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the anatomy and physiology of the endocrine glands. MNL Learning Outcome: 10.5.1. Explain the incidence, prevalence, and pathophysiology for diabetes. Page Number: 464
Question 44 Type: MCMA A patient is scheduled for a water deprivation test. What should the nurse instruct the patient to prepare for this test? Standard Text: Select all that apply. 1. Expect this test to take 16 hours to complete. 2. Abstain from smoking as directed by the health care 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 health care provider. 5. Blood and urine samples will be collected every hour during the test. Correct Answer: 2, 4, 5 Rationale 1: The water deprivation test takes up to 8 hours to complete. Rationale 2: For the water deprivation test, the patient should be instructed to not smoke as directed by the health care provider. Rationale 3: For the water deprivation test, a sedative is not needed. Rationale 4: For the water deprivation test, the patient should be instructed not to eat or drink as directed by the health care provider. Rationale 5: For the water deprivation test, blood samples for osmolality are taken when urine samples are collected each hour. Global Rationale: For the water deprivation test, the patient should be instructed not to smoke as directed by the health care provider. For the water deprivation test, the patient should be instructed to not eat or drink as directed by the health care provider. For the water deprivation test, blood samples for osmolality are taken when urine samples are collected each hour. The test will take up to 8 hours to complete. A sedative is not needed for this test. Cognitive Level: Applying Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX. 7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 1. Describe the anatomy and physiology of the endocrine glands. MNL Learning Outcome: 10.4.3. Examine the diagnosis and treatment of pituitary gland disorders. Page Number: 466
Question 45 Type: MCMA During a physical assessment the nurse suspects a patient is experiencing hypothyroidism. What skin assessment findings did the nurse use to make this assumption? Standard Text: 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 Correct Answer: 1, 3 Rationale 1: Rough, dry skin is often seen in patients with hypothyroidism. Rationale 2: Smooth, flushed skin can be a sign of hyperthyroidism. Rationale 3: A yellowish cast to the skin might indicate hypothyroidism. Rationale 4: Areas of hyperpigmentation may be seen in patients with Addison disease or Cushing syndrome. Rationale 5: Purple striae over the abdomen may be present in patients with Cushing syndrome. Global Rationale: Rough, dry skin is often seen in patients with hypothyroidism. A yellowish cast to the skin might indicate hypothyroidism. Smooth, flushed skin can be a sign of hyperthyroidism. Areas of hyperpigmentation may be seen in patients with Addison disease or Cushing syndrome. Purple striae over the abdomen may be present in patients with Cushing syndrome. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A. 1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 1. Conduct comprehensive and focused physical, behavioral, 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: 4. Explain techniques for assessing the thyroid gland and the effects of altered function of thyroid hormones. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 472
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Chapter 19 Question 1 Type: MCSA 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?” Correct Answer: 1 Rationale 1: The patient with hyperthyroidism can present with dry, warm skin, and the hair may become fine. Weight loss is another symptom of hyperthyroidism. Rationale 2: Constipation is a symptom of hypothyroidism or hyperparathyroidism. Dry, warm skin and hair that becomes fine are associated with another disorder. Rationale 3: Increased bruising is a sign of Cushing syndrome. Dry, warm skin and hair that becomes fine are associated with another disorder. Rationale 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. Global Rationale: The patient with hyperthyroidism can present with dry, warm skin, and the hair may become fine. Weight loss is a symptom of hyperthyroidism. Constipation is a symptom of hypothyroidism or hyperparathyroidism. Increased bruising is a sign of Cushing syndrome. A change in skin color is a sign of Addison disease. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 476 Question 2 Type: MCSA 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. Correct Answer: 1 Rationale 1: Hypoparathyroidism may result from manipulation of the parathyroid glands during a subtotal thyroidectomy. The lack of circulating PTH causes hypocalcemia. Neuromuscular manifestations that result from hypocalcemia include numbness and tingling around the mouth and in the fingertips. Rationale 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. Rationale 3: The improvement of hoarseness would be desired. Rationale 4: Antiplatelet agents, such as aspirin, should be withheld prior to surgery. Global Rationale: Hypoparathyroidism may result from manipulation of the parathyroid glands during a subtotal thyroidectomy. The lack of circulating PTH causes hypocalcemia. Neuromuscular manifestations that result from hypocalcemia include numbness and tingling around the mouth and in the fingertips. Constipation is associated with hypercalcemia, not hypocalcemia. The improvement of hoarseness would be desired. Antiplatelet agents, such as aspirin, should be withheld prior to surgery. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate patient teaching that reflects developmental stage, age, culture, spirituality, patient preferences, and health literacy considerations to foster patient engagement in their care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Provide appropriate nursing care for the patient before and after a subtotal thyroidectomy and an adrenalectomy. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 481 Question 3 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Hyperthyroidism is treated by administering methimazole or PTU, medications that reduce TH production, thereby decreasing metabolism. Rationale 2: Methimazole crosses the placenta and cannot be taken during pregnancy. Rationale 3: Antithyroid medications inhibit thyroid hormone production but have no effect on already-produced and circulating thyroid hormone. It can take several weeks for the patient to experience the effects. Rationale 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. Global Rationale: Hyperthyroidism is treated by administering methimazole or PTU, medications that reduce TH production, thereby decreasing metabolism. Methimazole crosses the placenta and cannot be taken during pregnancy. Antithyroid medications inhibit thyroid hormone production but have no effect on already-produced and circulating thyroid hormone. It can take several weeks for the patient to experience the effects. To rapidly reduce the cardiovascular symptoms associated with hyperthyroidism, propranolol (Inderal) or esmolol, a rapidacting parenteral beta-blocker may be used along with methimazole. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX. 9. Monitor client outcomes to evaluate the effectiveness of psychobiological interventions NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 479 Question 4 Type: MCSA 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.” Correct Answer: 1 Rationale 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. Rationale 2: Typically the scar fades to a small line, so plastic surgery is not needed. Rationale 3: Iodized salt and iodine preparations should not be taken with thyroid preparations. Rationale 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. Global Rationale: 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. Typically the scar fades to a small line, so plastic surgery is not needed. 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. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Provide appropriate nursing care for the patient before and after a subtotal thyroidectomy and an adrenalectomy. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 485 Question 5 Type: MCSA 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 Correct Answer: 1 Rationale 1: Proptosis changes the appearance of the eyes. The problem that would be a priority for the patient is a change in appearance. Rationale 2: Proptosis does not affect immune function. Rationale 3: Proptosis is associated with hyperthyroidism. There is a risk that the patient will lose weight. Rationale 4: Proptosis does not affect fluid balance. Global Rationale: Proptosis changes the appearance of the eyes. The problem that would be a priority for the patient is a change in appearance. Proptosis does not affect immune function or fluid balance. Proptosis is associated with hyperthyroidism; there is a risk that the patient will lose weight. Cognitive Level: Analyzing Client Need: Psychosocial Integrity Client Need Sub: 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 476 Question 6 Type: MCSA 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.” Correct Answer: 1 Rationale 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. Rationale 2: The nurse should not make assumptions about the patient’s dietary intake. Rationale 3: Comments about aging are not therapeutic. Rationale 4: Comments about eating at bedtime are not therapeutic. Global Rationale: 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. The nurse should not make assumptions about the patient’s dietary intake. Comments about aging and eating at bedtime are not therapeutic. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 483 Question 7 Type: MCSA 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 she has a daily bath.” 3. “Use firm, consistent strokes when bathing.” 4. “Follow the bath with a rubbing-alcohol massage.” Correct Answer: 1 Rationale 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. Rationale 2: The patient should bathe only when necessary. Rationale 3: Gentle motions should be used. Rationale 4: Alcohol-free oils and lotions should be used. Global Rationale: 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 bathe only when necessary, with warm, not hot, water. Gentle motions should be used. Alcohol-free oils and lotions should be used. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Basic Care and Comfort QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 486 Question 8 Type: MCMA The nurse is assessing a female patient who has an abnormally high level of parathyroid hormone. Which assessment findings would be consistent with this diagnosis? Standard Text: Select all that apply. 1. muscle atrophy 2. muscle weakness 3. diarrhea 4. weight gain 5. hypotension Correct Answer: 1, 2 Rationale 1: Manifestations of hyperparathyroidism are related to hypercalcemia. Elevated calcium levels alter neural and muscular activity, leading to muscle atrophy. Rationale 2: Manifestations of hyperparathyroidism are related to hypercalcemia. Elevated calcium levels alter neural and muscular activity, leading to muscle weakness. Rationale 3: Diarrhea is not a manifestation of hyperparathyroidism. Rationale 4: Weight gain is not a manifestation of hyperparathyroidism. Rationale 5: Hypotension is not a manifestation of hyperparathyroidism. Global Rationale: Manifestations of hyperparathyroidism are related to hypercalcemia. Elevated calcium levels alter neural and muscular activity, leading to muscle atrophy and weakness. Diarrhea, weight gain, and hypotension are not manifestations of hyperparathyroidism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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 LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 488 Question 9 Type: MCMA 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? Standard Text: Select all that apply. 1. facial grimacing 2. abdominal cramps 3. hair loss 4. dysrhythmias 5. smooth, soft skin Correct Answer: 1, 2, 3, 4 Rationale 1: Facial grimacing is a musculoskeletal manifestation of hypoparathyroidism. Rationale 2: Abdominal cramps are a gastrointestinal manifestation of hypoparathyroidism. Rationale 3: Hair loss is an integumentary manifestation of hypoparathyroidism. Rationale 4: Dysrhythmias are a cardiovascular manifestation of hypoparathyroidism. Rationale 5: Smooth, soft skin is not a common finding in the patient with hypoparathyroidism. Global Rationale: Facial grimacing, abdominal cramps, hair loss, and dysrhythmias are manifestations of hypoparathyroidism. Smooth, soft skin is not a common finding in the patient with hypoparathyroidism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in patients, using developmentally and culturally appropriate approaches LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Assessment Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 489 Question 10 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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. Rationale 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. Rationale 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. Global Rationale: 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. Poor wound healing, risk for compression fractures, and increased susceptibility to infections are common in patients who are being treated with steroids. However, these problems would not manifest as weight loss in the limbs. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.3.3. Examine the diagnosis and treatment of adrenal gland disorders. Page Number: 490 Question 11 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: While care should be taken during dressing changes to avoid infection, this will not prevent adrenal insufficiency. Rationale 3: Cortisol is often given on the day of surgery and in the postoperative period to replenish inadequate hormone levels. Rationale 4: Intravenous fluids are administered postoperatively. Global Rationale: 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. While care should be taken during dressing changes to avoid infection, this will not prevent adrenal insufficiency. Cortisol is often given on the day of surgery and in the postoperative period to replenish inadequate hormone levels. Intravenous fluids are also administered postoperatively. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 4. Provide appropriate nursing care for the patient before and after a subtotal thyroidectomy and an adrenalectomy. MNL Learning Outcome: 10.3.3. Examine the diagnosis and treatment of adrenal gland disorders. Page Number: 492 Question 12 Type: MCSA 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 Correct Answer: 1 Rationale 1: The patient with Cushing syndrome is at risk for infection due to the overproduction of glucocorticoids. The nurse should teach the importance of increasing intake of protein and vitamins C and A, which are all needed to support and repair body tissues. Rationale 2: Rest periods are recommended in the care of a patient with Cushing but would not address the problem of frequent infections. Rationale 3: Daily weights are recommended in the care of a patient with Cushing but would not address the problem of frequent infections. Rationale 4: There is no indication of a need to review or change coping strategies. Global Rationale: The patient with Cushing syndrome is at risk for infection due to the overproduction of glucocorticoids. The nurse should teach the importance of increasing intake of protein and vitamins C and A, which are all needed to support and repair body tissues. Rest periods and daily weights are recommended in the care of a patient with Cushing, but neither directly addresses the problem of frequent infections. There is no indication of a need to review or change coping strategies. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.3.4. Utilize the nursing process in care of client. Page Number: 492 Question 13 Type: MCSA A patient with an adrenal gland alteration does not understand why his skin is tanning when he does not spend any time 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 Correct Answer: 1 Rationale 1: Addison disease could develop if a patient abruptly stops taking steroids for a chronic health condition. Rationale 2: The patient has already reported that no time is spent outdoors in the sun. Rationale 3: Auscultation of lung sounds would not help in determining the cause of this skin change. Rationale 4: Palpation of the thyroid gland would not help in determining the cause of this skin change. Global Rationale: Addison disease could develop if a patient abruptly stops taking steroids for a chronic health condition. The patient has already reported that no time is spent outdoors in the sun. Auscultation of lung sounds and palpation of the thyroid gland would not help in determining the cause of this skin change. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.3.4. Utilize the nursing process in care of client. Page Number: 493 Question 14 Type: MCSA A patient comes into the emergency department with 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 Correct Answer: 1 Rationale 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. Rationale 2: The patient in Addisonian crisis may have a high fever, so warm blankets would not promote comfort or therapeutic action. Rationale 3: There is no thyroid hormone insufficiency. Rationale 4: There are no indications the patient is in need of a blood transfusion. Global Rationale: The patient with Addisonian crisis may have a high fever, weakness, abdominal pain, severe hypotension, circulatory collapse, shock, and coma. The crisis is treated with rapid intravenous replacement of fluids. The patient experiencing an Addisonian crisis may have a high fever, so warm blankets would not promote comfort or therapeutic action. There is no thyroid hormone insufficiency and no indications the patient is in need of a blood transfusion. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: Planning Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.3.4. Utilize the nursing process in care of client. Page Number: 494 Question 15 Type: MCSA 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.” Correct Answer: 1 Rationale 1: Corticosteroids may impair the effectiveness of oral contraceptives. Rationale 2: Corticosteroids may impair the effectiveness of oral contraceptives. Rationale 3: Daily weights have nothing to do with the interaction of oral contraceptives and steroids. Rationale 4: Limiting salt has nothing to do with the interaction of oral contraceptives and steroids. Global Rationale: Corticosteroids may impair the effectiveness of oral contraceptives. Daily weights and limiting salt have nothing to do with the interaction of oral contraceptives and steroids. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.3.4. Utilize the nursing process in care of client. Page Number: 495 Question 16 Type: MCSA The nurse is reviewing the relationship between thyroid hormone and iodine with a group of nursing students. The nurse knows further teaching is required when a student states that patients may experience iodine deficiency and hypothyroidism if they: 1. eat large amounts of shellfish. 2. use prescribed lithium carbonate. 3. eat large amounts of turnips or rutabagas. 4. live in an area where iodine is deficient in the soil. Correct Answer: 1 Rationale 1: Shellfish contains iodine. Rationale 2: Drugs such as lithium carbonate interfere with thyroid hormone synthesis. Rationale 3: Foods such as turnips and rutabagas interfere with thyroid hormone synthesis. Rationale 4: Living in an area where iodine is deficient in the soil may lead to thyroid deficiency and hypothyroidism. Global Rationale: Shellfish contains iodine. Drugs such as lithium carbonate and foods such as turnips and rutabagas interfere with thyroid hormone synthesis. Living in an area where iodine is deficient in the soil may also lead to thyroid deficiency and hypothyroidism. Cognitive Level: Analyzing Client Need: Health Promotion and Maintenance Client Need Sub: 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Page Number: 483 Question 17 Type: MCMA The nurse is reviewing orders for a patient in myxedema coma. Which orders should the nurse question before administering to this patient? Standard Text: 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 Correct Answer: 1,2,3 Rationale 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. Rationale 2: Patients with myxedema are often hypothermic, and a cooling blanket would be harmful. Rationale 3: Methimazole (Tapazole) interferes with thyroid hormone and would be contraindicated for a patient in myxedema coma. Rationale 4: Hourly vital signs with oximetry are appropriate for this patient. Rationale 5: Daily serum TSH monitoring is appropriate for this patient. Global Rationale: Myxedema coma is characterized by hypoglycemia. There is no evidence that IV insulin is indicated for this patient, and administering it would likely be harmful to an already hypoglycemic patient. Patients with myxedema are often hypothermic, and a cooling blanket would also be harmful. Methimazole (Tapazole) interferes with thyroid hormone and would be contraindicated for a patient in myxedema coma. Hourly vital signs with oximetry and daily serum TSH monitoring are appropriate for this patient. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 483 Question 18 Type: MCMA 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? Standard Text: Select all that apply. 1. gastrointestinal bleeding 2. pneumonia 3. excessive use of thyroid replacement medications 4. excessive use of central nervous system stimulants 5. exposure to excessive heat and humidity Correct Answer: 1, 2 Rationale 1: Myxedema coma may be precipitated by gastrointestinal bleeding. Rationale 2: Myxedema coma may be precipitated by pneumonia. Rationale 3: Excessive use of thyroid replacement medications would not precipitate myxedema coma. Rationale 4: Excessive use of central nervous system stimulants would not precipitate myxedema coma. Rationale 5: Exposure to heat and humidity would not precipitate myxedema coma. Global Rationale: Myxedema coma usually occurs in older adults and may be precipitated by pneumonia, gastrointestinal bleeding, and the use of central nervous system depressants. Excessive use of thyroid replacement medications, central nervous system stimulants, or exposure to heat and humidity would not precipitate myxedema coma. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.5. Deliver compassionate, patient-centered, evidence-based care that respects patient and family preferences NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 483 Question 19 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 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. Rationale 3: TSH is depressed in hyperthyroidism. Rationale 4: TSH is depressed in hyperthyroidism. Global Rationale: 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. Elevated T3 and T4 levels are not consistent with hypothyroidism. TSH is depressed in hyperthyroidism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 479, 483 Question 20 Type: MCMA The nurse is caring for a patient with untreated hypothyroidism. For which health problems should the nurse assess this patient? Standard Text: Select all that apply. 1. elevated serum cholesterol 2. anemia 3. hyperglycemia 4. hypernatremia 5. decreased serum LDL Correct Answer: 1, 2 Rationale 1: Untreated hypothyroidism increases the risk for abnormalities in lipid metabolism. Rationale 2: Anemia is common in untreated hypothyroidism. Rationale 3: Hyperglycemia is not associated with untreated hypothyroidism. Rationale 4: Hypernatremia is not associated with untreated hypothyroidism. Rationale 5: Untreated hypothyroidism increases the risk for abnormal lipid metabolism. Global Rationale: Untreated hypothyroidism increases the risk for abnormalities in lipid metabolism. Anemia is also common in this disorder. Hyperglycemia and hypernatremia are not associated with this disorder. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 483 Question 21 Type: MCSA The nurse is teaching a group of older adults about thyroid hormone replacement. The nurse realizes teaching has been ineffective when one participant states that older adults may be at risk for too much thyroid medication in their blood because of which factor? 1. high blood lipid levels 2. less albumin in the blood to bind to thyroid medication 3. kidney alterations that make the organs less efficient at removing medications from the blood 4. polypharmacy, leading to problems with medication dosing and administration Correct Answer: 1 Rationale 1: Elevated serum lipids are not associated with increased thyroid hormone levels in patients taking thyroid hormone replacement. Rationale 2: Older adults are at risk for hypoalbuminemia, which can lead to elevated levels of thyroid hormone in the bloodstream. Rationale 3: Older adults are at risk for decreased kidney function, which can lead to elevated levels of thyroid hormone in the bloodstream. Rationale 4: Older adults are at risk for polypharmacy, which can lead to elevated levels of thyroid hormone in the bloodstream. Global Rationale: Elevated serum lipids are not associated with increased thyroid hormone levels in patients taking thyroid hormone replacement. Older adults are at risk for hypoalbuminemia, decreased kidney function, and polypharmacy, all of which can lead to elevated levels of thyroid hormone in the bloodstream. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Pharmacological and Parenteral Therapies 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.1.3. Examine the diagnosis and treatment of thyroid disorders. Page Number: 483 Question 22 Type: MCMA The nurse is assessing a patient with hypothyroidism. Which findings should the nurse expect for this patient? Standard Text: Select all that apply. 1. change in heart rate from 80 bpm to 60 bpm on auscultation 2. decreased stroke volume from 70 mL/beat to 50 mL/beat per echocardiogram 3. new finding of pericardial effusion per chest x-ray 4. left descending coronary artery narrowing per angiogram 5. increased cardiac output from 3,000 mL/min to 4,000 mL/min per echocardiogram Correct Answer: 1, 2, 3, 4 Rationale 1: A thyroid hormone deficit causes a reduction in heart rate, resulting in decreased cardiac output. Rationale 2: A thyroid hormone deficit causes a decreased stroke volume, resulting in decreased cardiac output. Rationale 3: There may be an accumulation of fluid in the pericardial sac. Rationale 4: Coronary artery disease may be present. Rationale 5: Increased cardiac output is not associated with hypothyroidism. Global Rationale: A thyroid hormone deficit causes a reduction in heart rate and stroke volume, resulting in decreased cardiac output. There may also be an accumulation of fluid in the pericardial sac, and coronary artery disease may be present. Increased cardiac output is not associated with hypothyroidism. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.2. Differentiate the manifestations of thyroid disorders. Page Number: 485 Question 23 Type: MCMA The nurse is teaching a patient who has a diagnosis of hypothyroidism about the importance of dietary fiber. Which statements by the patient indicate that teaching has been effective? Standard Text: Select all that apply. 1. “I will drink a full glass of water with my fiber pill each morning.” 2. “I will snack on popcorn 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.” Correct Answer: 1, 2 Rationale 1: A full glass of water should be taken with fiber tablets to reduce the risk of intestinal blockage. Rationale 2: Popcorn is a high-fiber food and an appropriate choice for a patient who needs a high-fiber diet. Rationale 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. Rationale 4: Meat and eggs are not good sources of fiber. Rationale 5: This patient should look for fiber content rather than carbohydrate content on labels. Global Rationale: A full glass of water should be taken with fiber tablets to reduce the risk of intestinal blockage. Popcorn is a high-fiber food and an appropriate choice for a patient who needs a high-fiber diet. The patient should not ingest a high-fiber source at the same time as thyroid replacement medications, as the fiber will LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
interfere with absorption of the medication. Meat and eggs are not good sources of fiber. This patient should look for fiber content rather than carbohydrate content on labels. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.4. Utilize the nursing process in care of client. Page Number: 485-486 Question 24 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Exposure to products used in refinishing furniture is not a risk factor for thyroid cancer. Rationale 3: A diet of red meat is not a risk factor for thyroid cancer. Rationale 4: Failing to use sunscreen when working outdoors is not a risk factor for thyroid cancer. Global Rationale: 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. Exposure to products used in refinishing furniture, a diet of red meat, and failing to use sunscreen when working outdoors are not risk factors for thyroid cancer. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.1.1. Explain the causes, risk factors, incidence, and pathophysiology of thyroid disorders. Page Number: 487 Question 25 Type: MCMA The nurse is reviewing the manifestations of hyperparathyroidism with a patient. Which statements by the patient indicate that teaching has been effective? Standard Text: 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.” Correct Answer: 1, 2, 3, 4 Rationale 1: Hyperparathyroidism is characterized by increased resorption of calcium and excretion of phosphate by the kidneys, which increases the risk of hypercalcemia and hypophosphatemia. Rationale 2: Hyperparathyroidism increases the release of calcium and phosphorus by the bones, with resultant bone decalcification. Rationale 3: The increase in PTH affects the kidneys and bones, leading to the deposit of calcium in soft tissues. Rationale 4: Renal calculi can form. Rationale 5: Hyperparathyroidism causes the kidneys to lower blood pH and excrete potassium. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: Hyperparathyroidism is characterized by increased resorption of calcium and excretion of phosphate by the kidneys, which increases the risk of hypercalcemia and hypophosphatemia. The release of calcium and phosphorus by the bones can lead to bone decalcification, deposit of calcium in soft tissues, and the formation of renal calculi. Hyperparathyroidism causes the kidneys to lower blood pH and excrete potassium. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 488 Question 26 Type: MCMA The nurse is instructing a patient about the symptoms of hyperparathyroidism. Which symptoms should the nurse include in this discussion? Standard Text: Select all that apply. 1. abdominal pain 2. dysrhythmias 3. hypertension 4. diarrhea 5. reduced urine output Correct Answer: 1, 2, 3 Rationale 1: Hyperparathyroidism can cause abdominal pain. Rationale 2: Hyperparathyroidism can cause dysrhythmias. Rationale 3: Hyperparathyroidism can cause hypertension. Rationale 4: Diarrhea is not associated with hyperparathyroidism. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Rationale 5: Reduced urine output is not associated with hyperparathyroidism. Global Rationale: Hyperparathyroidism can cause abdominal pain, dysrhythmias, and hypertension. Diarrhea and reduced urine output are not manifestations of hyperparathyroidism. Cognitive Level: Applying Client Need: Health Promotion and Maintenance Client Need Sub: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.2. Differentiate the manifestations of parathyroid disorders. Page Number: 488 Question 27 Type: MCSA The nurse is assessing a patient with hyperparathyroidism who 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 Correct Answer: 1 Rationale 1: Hyperparathyroidism increases sensitivity to cardiotonic glycosides such as digoxin. The patient should be assessed for toxic effects of this medication. Rationale 2: The medication dose will unlikely need to be increased. Rationale 3: Polyuria is a manifestation of hyperparathyroidism. Rationale 4: Muscle weakness and atrophy are manifestations of hyperparathyroidism. Global Rationale: Hyperparathyroidism increases sensitivity to cardiotonic glycosides such as digoxin. The patient should be assessed for toxic effects of this medication. It is unlikely the dose will need to be increased. Polyuria, muscle weakness, and muscle atrophy are manifestations of hyperparathyroidism. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.2.4. Utilize the nursing process in care of client. Page Number: 488 Question 28 Type: MCSA The nurse is assessing a patient’s understanding of hyperparathyroidism. The nurse knows further teaching is needed when the patient states that the primary health care provider can determine the patient has hyperparathyroidism when: 1. the patient has experienced at least two episodes of severe abdominal pain. 2. all other causes of high blood calcium levels have been ruled out. 3. the patient has had the symptoms of hyperparathyroidism for at least 6 months. 4. the patient’s blood tests show high calcium and high parathyroid hormone levels. Correct Answer: 1 Rationale 1: Two episodes of abdominal pain may be symptomatic of hyperparathyroidism but are not diagnostic criteria. Rationale 2: Hyperparathyroidism is diagnosed by excluding all other possible causes of hypercalcemia. Rationale 3: Hyperparathyroidism is diagnosed by at least a six-month history of manifestations. Rationale 4: Hyperparathyroidism is diagnosed by laboratory analysis of serum calcium and PTH levels. Global Rationale: Two episodes of abdominal pain may be symptomatic of hyperparathyroidism but are not diagnostic criteria. Hyperparathyroidism is diagnosed by excluding all other possible causes of hypercalcemia, by at least a six-month history of manifestations, and by laboratory analysis of serum calcium and PTH levels. Cognitive Level: Analyzing Client Need: Physiological Integrity LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Evaluation Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.3. Examine the diagnosis and treatment of parathyroid disorders. Page Number: 488 Question 29 Type: MCMA 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? Standard Text: Select all that apply. 1. promoting ambulation and mobility 2. discussing a change from ordered thiazide diuretics to another type of diuretic with health care 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 Correct Answer: 1, 2, 3 Rationale 1: Treatment of hyperparathyroidism focuses on reducing elevated serum calcium levels. Patients with mild hypercalcemia are urged to keep active and avoid immobilization. Rationale 2: Patients with mild hypercalcemia are urged to avoid thiazide diuretics. Rationale 3: Patients with mild hypercalcemia are urged to increase fluid intake. Rationale 4: Patients with mild hypercalcemia are urged to avoid large doses of vitamins A and D. Rationale 5: Patients with mild hypercalcemia are urged to avoid antacids containing calcium. Global Rationale: Treatment of hyperparathyroidism focuses on reducing elevated serum calcium levels. Patients with mild hypercalcemia are urged to avoid immobilization, thiazide diuretics, large doses of vitamins A and D, and antacids containing calcium. Patients with mild hypercalcemia are urged to increase fluid intake. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Physiological Integrity QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.3. Examine the diagnosis and treatment of parathyroid disorders. Page Number: 488 Question 30 Type: MCSA 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. Correct Answer: 1 Rationale 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. Rationale 2: Calcimimetic does not block calcium receptors in the nervous and musculoskeletal systems. Rationale 3: Calcimimetic does not decrease the resorption of calcium in the distal renal tubule. Rationale 4: Calcimimetic does not bind calcium to bile salts to excrete through the GI tract. Global Rationale: 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. Calcimimetic does not block calcium receptors in the nervous and musculoskeletal systems, decrease the resorption of calcium in the distal renal tubule, or bind calcium to bile salts to excrete through the GI tract. Cognitive Level: Applying LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.7. Provide appropriate 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 3. Explain the nursing implications for medications prescribed to treat disorders of the thyroid and adrenal glands. MNL Learning Outcome: 10.2.3. Examine the diagnosis and treatment of parathyroid disorders. Page Number: 488 Question 31 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: Confusion is not a manifestation of hypoparathyroidism and low calcium level. Rationale 3: Renal function changes are not a manifestation of hypoparathyroidism and low calcium level. Rationale 4: Problems with oxygenation are not a manifestation of hypoparathyroidism and low calcium level. Global Rationale: 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. Confusion, renal function changes, and problems with oxygenation are not manifestations of hypoparathyroidism and a low calcium level. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Reduction of Risk Potential QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Planning Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.4. Utilize the nursing process in care of client. Page Number: 488 Question 32 Type: MCMA The nurse is caring for a patient with hypoparathyroidism. What actions should the nurse expect to perform to help this patient with a low calcium level? Standard Text: 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 Correct Answer: 1, 2, 4 Rationale 1: Treatment of hypoparathyroidism focuses on increasing calcium levels. Long-term therapy includes supplemental calcium. Rationale 2: Treatment of hypoparathyroidism focuses on increasing calcium levels. Long-term therapy includes increased dietary calcium. Rationale 3: Fluids are not restricted in the treatment of hypoparathyroidism. Rationale 4: Treatment of hypoparathyroidism focuses on increasing calcium levels. Intravenous calcium gluconate is given immediately to reduce tetany. Rationale 5: Treatment of hypoparathyroidism focuses on increasing calcium levels. Calcimimetic would reduce the amount of calcium in the body. Global Rationale: Treatment of hypoparathyroidism focuses on increasing calcium levels. Intravenous calcium gluconate is given immediately to reduce tetany. Long-term therapy includes supplemental calcium and increased LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
dietary calcium. Fluids are not restricted in the treatment of hypoparathyroidism. Calcimimetic would reduce the amount of calcium in the body. Cognitive Level: Applying Client Need: Physiological Integrity Client Need Sub: Pharmacological and Parenteral Therapies QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care 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; conduct population-based transcultural health assessments and interventions Nursing/Integrated Concepts: Nursing Process: Implementation Learning Outcome: 5. Use the nursing process as a framework for providing individualized care to patients with disorders of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.2.4. Utilize the nursing process in care of client. Page Number: 488 Question 33 Type: MCSA 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 Correct Answer: 1 Rationale 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. Rationale 2: A weight change is not a manifestation of infection in a patient with chronic hyperfunction of the adrenal cortex. Rationale 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. Rationale 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.
LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.
Global Rationale: 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. Weight change, muscle tremors, and nervous energy are not manifestations of infection in the patient with chronic hyperfunction of the adrenal cortex. Cognitive Level: Analyzing Client Need: Physiological Integrity Client Need Sub: Physiological Adaptation QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of patient centered care AACN Essentials Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, 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: 2. Compare and contrast the manifestations of disorders that result from hyperfunction and hypofunction of the thyroid, parathyroid, adrenal, and pituitary glands. MNL Learning Outcome: 10.3.2. Differentiate the manifestations of adrenal gland disorders. Page Number: 492 Question 34 Type: MCSA 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 Correct Answer: 1 Rationale 1: The patient who received radioactive iodine treatment for hyperthyroidism is not at increased risk for Cushing syndrome. Rationale 2: Patients receiving treatment for rheumatoid arthritis are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome. Rationale 3: Patients with organ transplants are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome. Rationale 4: Patients receiving chemotherapy are frequently prescribed corticosteroids, which are a primary risk factor for Cushing syndrome. LeMone/Burke/Bauldoff/Gubrud, Medical-Surgical Nursing 6th Edition Test Bank Copyright 2015 by Pearson Education, Inc.