Adult Health Nursing 7th Edition By Cooper Gosnell –
Chapter 1: Introduction to Anatomy and Physiology
- The anatomic term ____ means toward the midline.
The term medial indicates an anatomic direction toward the midline.
- What are the smallest living components in our body?
- What is the largest organelle, responsible for cell reproduction and control of other organelles?
- When the patient complains of pain in the bladder, the patient will indicate discomfort in which body cavity?
- The four phases of cell division all occur in:
TOP: Cell division
- Telophase is which phase of cell reproduction during mitosis?
TOP: Cell division
- The nurse is aware that which muscle group is both striated and involuntary?
-10, Figure 1-12
- What is a group of several different kinds of tissues arranged so that together they can perform a more complex function than any tissue alone?
When several kinds of tissues are united to perform a more complex function than any tissue alone, they are called organs.
1 OBJ: 7
- What traits describe visceral muscles?
|a.||Smooth and voluntary|
|b.||Smooth and involuntary|
|c.||Striated and voluntary|
|d.||Striated and involuntary|
- How are the thoracic and abdominal cavities separated?
|a.||By the pleura|
|b.||By the diaphragm|
|c.||By the sagittal plane|
|d.||By the peritoneum|
- What is the broad section of biology dealing with the description of human structure?
- ____ explains the processes and functions of many structures of the body and how they interact with one another.
- The anatomic structure that is not in the thoracic cavity is/are the _____.
- When several organs and parts are grouped together for certain functions, they form:
- What are the distinct surface proteins of the plasma membrane essential in determining?
|c.||Effectiveness of a drug|
- In anatomic terminology, posterior means toward the:
- What does the transverse body plane divide?
|a.||The front and back (coronal) of the body|
|b.||The body lengthwise (two equal halves)|
|c.||The superior and inferior portions of the body|
|d.||The body into axial and appendicular|
- Caudal is defined as toward the ____.
- What is the term for movement of water from an area of lower solute concentration to an area of higher solute concentration?
- What is the type of tissue composed of cells that contract in response to a message from the brain or spinal cord?
- What is the type of tissue associated with the storage of fat?
- What are the thin sheets of tissue that lubricate and line the body surfaces that open to the outside environment?
|d.||Involuntary visceral muscles|
- What is the process by which a cell digests a foreign material by surrounding it?
- Active transport in the movement of ions and other water-soluble particles across cell membranes requires that the body uses its::
|c.||a chemical pump.|
- What is the term for the passage of water containing dissolved materials through a membrane as the result of a greater mechanical force on one side?
- The nurse is aware that when a patient complains of pain in the epigastric region, the source of the pain is most likely to be a disorder involving the:
- What are tissues that cover the outside of the body and some internal structures?
- When the nurse assesses an arm in proximal to distal order, the assessment is performed from:
|a.||the shoulder to the fingers.|
|b.||front to back.|
|c.||fingers to the center of the body.|
|d.||center of the body to the fingers.|
- What is the function of epithelial membranes?
|a.||Secretes mucus, lines ends of bones, and lines bursae|
|b.||Lines ends of bones, secretes synovial fluid, and lines internal surfaces of organs|
|c.||Covers the wall of lower digestive tract, secretes mucus, and lines lungs, peritoneum, and pericardium|
|d.||Lines lungs, peritoneum, and pericardium, and secretes synovial fluid|
- The nurse explains that pinocytosis is a process by which cells:
|b.||take in extracellular fluid.|
|c.||use a chemical pump.|
- Which are among the 11 body systems? (Select all that apply.)
- Which of the following are characteristics of visceral muscles? (Select all that apply.)
|d.||Independent from the spinal cord|
|f.||Present in the blood vessels|
- Which of the following are passive transport mechanisms that move material across the cell membranes? (Select all that apply.)
- The nurse clarifies that the dorsal cavity is composed of the (select all that apply) :
- The nurse clarifies that the three functions of epithelial tissue are _____________,___________, and __________.
- The nurse explains that ___________are small saclike structures inside the cell that digest compounds that have invaded the cell.
- The body plane that divides the body into the ventral and dorsal section is the_________ plane.
- List in order of increasing complexity the structural levels of organization of the body. (Separate letters by a comma and space as follows: A, B, C, D)
- Body as a whole
- Place the body structures in cranial-caudal priority. (Separate letters by a comma and space as follows: A, B, C, D)
- Using a poster, the nurse demonstrates the protection of the nucleus. Arrange the layers starting with the most superficial. (Separate letters by a comma and space as follows: A, B, C, D)
- Endoplasmic reticulum
- Nuclear membrane
- Plasma membrane
Chapter 2: Care of the Surgical Patient
- The patient who had a nephrectomy yesterday has not used the patient-controlled analgesia (PCA) delivery system but admits to being in pain but fearful of addiction. What is the nurse’s best response?
|a.||“Modern analgesic drugs do not cause addiction.”|
|b.||“Pain relief is worth a short period of addiction.”|
|c.||“Addiction rarely occurs in the brief time postsurgical analgesia is required.”|
|d.||“Addiction could be a real concern.”|
- A 73-year-old patient with diabetes was admitted for below-the-knee amputation of his right leg. Removal of his right leg is an example of which type of surgery?
- In which situation might surgery be delayed?
|a.||The patient has taken Dilantin today.|
|b.||An illegible signature is on the consent form..|
|c.||The patient is still taking anticoagulants.|
|d.||The admission office is unable to confirm insurance coverage.|
- Which circumstance could prevent the patient from signing his informed consent for a cholecystectomy?
|a.||The patient complains of pain radiating to the scapula.|
|b.||The patient received an injection of Demerol, 75 mg IM, 1 hour ago.|
|c.||The patient is 85 years of age.|
|d.||The patient is concerned over his lack of insurance coverage.|
- The nurse anticipates that the patient will be given ______________anesthesia because of the extensive tissue manipulation involved in a hysterectomy.
- The nurse caring for a patient who had an epidural block for a vaginal repair should be alert for:
|a.||a flushing of the face and torso.|
|b.||numbness of the perineum.|
|c.||complaint of thirst.|
|d.||a sudden drop in blood pressure.|
- Why might the older adult patient not respond to surgical treatment as well as a younger adult patient?
|a.||Poor skin turgor|
|b.||Fear of the unknown|
|c.||Response to physiological changes|
|d.||Decreased peristalsis related to anesthesia|
- The postoperative nursing intervention that would be contraindicated for a 45-year-old patient who has had a repair of a cerebral aneurysm and is presenting signs of increased intracranial pressure (ICP) would be:
|a.||coughing every 2 hours.|
|b.||turning every 2 hours.|
|c.||monitoring intravenous therapy at 50 ml/hr.|
|d.||assessing vital signs every 2 hours.|
- The nurse acting as a circulating nurse has a responsibility for:
|a.||observing for breaks in sterile technique.|
|b.||identifying and handling surgical specimens correctly.|
|c.||assisting with surgical draping of the patient.|
|d.||maintaining count of sponges, needles, and instruments during surgery.|
- Which statement made by a patient during a preoperative assessment would be significant to report to the charge nurse and surgeon?
|a.||“I have been taking an herbal product of feverfew for my migraines.”|
|b.||“I exercise for 3 hours a day.”|
|c.||“I drink 2 glasses of wine a day.”|
|d.||“I use atropine eyedrops every day.”|
- A patient is on postoperative day 2 after a nephrectomy. What is the most effective way to increase her peristalsis?
|c.||Encouraging hot liquids|
|d.||Administering a laxative|
- A patient is transferred from the operating room to the recovery room after undergoing an open reduction and internal fixation (ORIF) of his left ankle. Which is the first assessment to make?
|a.||Check ankle dressings for hemorrhage.|
|b.||Check airway for patency.|
|c.||Check intravenous site.|
|d.||Check pedal pulse.|
- Frequent assessment of a postoperative patient is essential. What is one of the first signs and symptoms of hemorrhage?
|a.||Increasing blood pressure|
- The nurse instructing a postsurgical patient in the use of thrombolytic deterrent stockings would include which of the following instructions?
|a.||Disregard appearance of edema above the stocking|
|b.||Massage legs to smooth wrinkles out of stockings|
|c.||Wring stockings thoroughly before hanging to dry|
|d.||Wash stockings in warm water and mild soap|
- The patient is brought into PACU still unconscious. What should the nurse do when the nurse assesses an oral temperature of 94° F?
|a.||Notify the charge nurse immediately|
|b.||Offer warm fluids through a straw|
|c.||Do nothing, this is a normal reaction to anesthesia|
|d.||Cover with a warm blanket|
- In which location are guidelines for ensuring that all nursing interventions on the day of surgery completed and documented?
|a.||In the nurse’s notes|
|b.||In the anesthesia record|
|c.||In the preoperative checklist|
|d.||In the progress notes|
- While turning a patient who had a bowel resection yesterday, the wound eviscerated. What is the initial nursing intervention?
|a.||Place the patient in the high Fowler’s position.|
|b.||Give the patient fluids to prevent shock.|
|c.||Replace the dressing with sterile fluffy pads.|
|d.||Apply a warm, moist normal saline sterile dressing.|
- When should the nurse offer prescribed analgesics to a patient who is 24 hours postoperative?
|a.||Only when the patient asks.|
|b.||When the onset of pain is assessed.|
|c.||Sparingly to avoid drug dependence.|
|d.||Only when severe pain is assessed.|
- What should the nurse do to minimize the potential for venous stasis?
|a.||Place pillows under the knee in a position of comfort|
|b.||Assist patient to sit with feet flat on the floor|
|c.||Assist with early ambulation|
|d.||Perform gentle leg massage|
- The nurse clarifies that serum potassium levels are determined before surgery to:
|a.||assess kidney function.|
|b.||determine respiratory insufficiency.|
|c.||prevent arrhythmias related to anesthesia.|
|d.||measure functional liver capability.|
- In performing the preoperative assessment, the nurse discovers that the patient is allergic to latex. What should the nurse do initially?
|a.||Notify the diet kitchen to omit peaches from diet tray|
|b.||Apply a medical alert band to patient’s wrist|
|c.||Tag chart with allergy alert|
|d.||Place patient in an isolation room|
- Which of the following early postoperative observations should be reported immediately?
|a.||“Coffee ground” emesis|
|c.||Scanty urine output|
|d.||Evidence of pain|
- When the postoperative patient complains of sudden chest pain combined with dyspnea, cyanosis, and tachycardia, the nurse recognizes the signs of:
- The removal of a nondiseased appendix during a hysterectomy is classified as:
|a.||major, emergency, diagnostic|
|b.||major, urgent, palliative|
|c.||minor, elective, ablative|
|d.||minor, urgent, reconstructive|
- Which medication would cause surgery to be delayed if it had not been discontinued several days before surgery?
- The most appropriate intervention by the nurse to decrease the pain of an abdominal incision while coughing would be to:
|a.||Support the surgical site with a pillow|
|b.||Position patient in a side-lying position|
|c.||Medicate with prescribed narcotic before coughing|
|d.||Ask the patient to cross arms over the chest to increase force of cough|
- The nurse would include the nursing diagnosis of deficient knowledge, postoperative, when the patient scheduled for a bowel resection tomorrow remarks:
|a.||“I am going to have adequate pain medication after surgery.”|
|b.||“I know you all are going to make me cough and walk soon after surgery.”|
|c.||”I am glad I will get to go home tomorrow evening.”|
|d.||“I will have to put up with dressing changes.”|
- What instruction should a nurse give when teaching the patient to cough effectively after surgery?
|a.||Breathe through the nose, hold breath, and exhale slowly.|
|b.||Take three deep breaths and cough from the chest.|
|c.||Inhale while contracting the abdominal muscles and exhale while contracting the diaphragm.|
|d.||Take short, frequent panting breaths and cough from the throat to clear accumulated mucus.|
- What is the responsibility of the nurse as a witness to informed consent?
|a.||Explain the surgical options|
|b.||Explain the operative risks|
|c.||Verify/obtain the patient’s signature|
|d.||Verify the patient’s understanding of the procedure|
- On the patient’s return to the medical-surgical unit, the nurse performing an abdominal assessment can affirm an absence of bowel sounds after listening in each quadrant for at least:
- When the patient asks the nurse to make sure no one sees her with her dentures out, the nurse recognizes the common preoperative fear of:
|b.||loss of control.|
|c.||fear of separation from family.|
- What is the ideal time for preoperative teaching?
|a.||Immediately before surgery to eliminate fear|
|b.||2 months in advance so the patient can prepare|
|c.||1 to 2 days before the surgery when anxiety is not as high|
|d.||In the surgical holding area|
- In preparation for the return of the surgical patient, the patient’s bed and equipment should be in what position?
|a.||Lowest position with side rails elevated with oxygen and suction equipment available|
|b.||Highest position with side rails elevated with IV pole and pump at bedside|
|c.||Lowest position with side rails down on the receiving side|
|d.||Highest position with the side rails down on receiving side and up on opposite side|
- A postoperative patient who had a left inguinal hernia repair is ready for his discharge instructions. Which information should the nurse provide? (Select all that apply.)
|a.||Care of the wound site and any dressings|
|b.||When he may operate a motor vehicle|
|c.||Signs and symptoms to report to the physician|
|d.||Call the physician’s office once he arrives home|
|e.||Report bowel movements to the physician|
|f.||Actions and side effects of any medications|
- Which of the following are considerations for the older adult surgical patient? (Select all that apply.)
|a.||The need for specific clear preoperative and postoperative teaching|
|b.||Awareness of lower morbidity and mortality rate|
|c.||Presence of coexisting conditions|
|d.||Increased risk of respiratory complications|
|e.||Expectation of normal recovery time|
- Which of the following are preoperative conditions that may affect the patient’s response to surgery? (Select all that apply.)
- Which interventions in preparing the patient for abdominal surgery may be delegated to unlicensed assistive personnel (UAP)?
|b.||Insertion of N/G tube|
|d.||Height and weight|
|e.||Obtaining operative consent|
- ______________ therapy is performed to alleviate or decrease uncomfortable symptoms without curing the problem.
- Discharge planning for a surgical procedure begins in the ______________ period and continues through the _____________ period.
- The type of anesthesia that uses a combination of drugs to reduce the level of consciousness and provides amnesia is _________________ __________.
- The nurse is aware that there is a loss of _________ during catabolism after severe tissue injury.
- The nurse explains that to promote deep breathing and improve lung expansion and oxygenation the patient should use the _____________ ______________ at regular intervals during the day.
- The nurse caring for a postsurgical patient is aware that the patient should void ____ to _____ hours postsurgery.
- A patient is transferred from the operating room to the recovery room after undergoing an amputation of his left foot. Place the interventions in the correct order for immediate assessment once the patient enters the PACU. (Separate letters by a comma and space as follows: A, B, C, D)
- System review
- Level of consciousness
- Place the instructions for controlled coughing in the correct sequence. (Separate letters by a comma and space as follows: A, B, C, D)
- Inhale deeply and hold breath for a count of three
- Document exercise and patient reaction
- Cough 2 or 3 times without inhaling then relax
- Take several deep breaths
- Inhale through nose
- Exhale through pursed lips
Chapter 3: Care of the Patient with an Integumentary Disorder
- What should the nurse do when administering a therapeutic bath to a patient who has severe pruritus?
|a.||Use Burow’s solution to help promote healing|
|b.||Rub the skin briskly to decrease pruritus|
|c.||Limit bathing to 3 times a week|
|d.||Ensure that bath area is at least 85 degrees and dehumidified|
- A frail, older adult home health patient who had chickenpox as a child has been exposed to varicella (chickenpox) several days ago. What should the nurse do?
|a.||Assess frequently for herpes zoster|
|b.||Be aware of the patient’s immunity to chickenpox|
|c.||Encourage the patient to have a pneumonia vaccine|
|d.||Arrange for the patient to receive gamma globulin|
- A patient has herpes zoster (shingles) and is being treated with acyclovir (Zovirax). What should the nurse do when administering this drug?
|a.||Apply lightly, being careful not to completely cover the lesion|
|b.||After application, wrap in warm wet dressings|
|d.||Rub medication into lesions|
- A child has been sent to the school nurse with pruritus and honey-colored crusts on the lower lip and chin. The nurse believes these lesions most likely are:
|d.||herpes simplex type I.|
- A school nurse assesses a child who has an erythematous circular patch of vesicles on her scalp with alopecia and complains of pain and pruritus. Why would the nurse use a Woods lamp?
|a.||To dry out the lesions|
|b.||To reduce the pruritus|
|c.||To kill the fungus|
|d.||To cause fluorescence of the infected hairs|
- A patient, age 46, reports to his physician’s office with urticaria with elevated lesions that are white in the center with a pale red border on hands and arms. He says, “It itches like crazy.” Which type of lesion would the nurse include in her documentation?
- The home health nurse assessing skin lesions uses the PQRST mnemonic as a guide. What does the S in this guide indicate?
|a.||Severity of the symptoms|
|b.||Site of the lesions|
|c.||Symptomatology of the lesions|
|d.||Surface area of the lesions|
- What would the nurse stress to the 17-year-old girl who has been prescribed Accutane for her acne?
|a.||Avoid alcoholic beverages|
|b.||Drink at least 1000 mL of fluid daily|
|c.||Use dependable birth control to avoid pregnancy|
|d.||Avoid exposure to the sun|
- A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?
- A patient, age 37, sustained partial- and full-thickness burns to 26% of the body surface area. When would the greatest fluid loss resulting from the burns occur?
|a.||Within 12 hours after burn trauma|
|b.||24 to 36 hours after burn trauma|
|c.||24 to 48 hours after burn trauma|
|d.||48 to 72 hours after burn trauma|
- Most of the deaths from burn trauma in the emergent phase that require a referral to a burn center result from:
|b.||arrhythmias with cardiac arrest.|
|c.||hypovolemic shock and renal failure.|
- The nurse takes into consideration that carbon monoxide intoxication secondary to smoke inhalation is often fatal because carbon monoxide:
|a.||binds with hemoglobin in place of oxygen.|
|b.||interferes with oxygen intake.|
|c.||is a respiratory depressant.|
|d.||is a toxic agent.|
- A nurse arrives at an accident scene where the victim has just received an electrical burn. What is the nurse’s primary concern?
|a.||The extent and depth of the burn|
|b.||The sites of entry and exit|
|c.||The likelihood of cardiac arrest|
|d.||Control of bleeding|
- A patient, age 27, sustained thermal burns to 18% of her body surface area. After the first 72 hours, the nurse will have to observe for the most common cause of burn-related deaths, which is:
- Two weeks after a severe burn of over 20% of the body, the patient vomits bright red blood. Which condition is most likely?
|c.||Hypoglycemia perforation of the stomach by the NG tube|
- When providing the open method of treatment for a patient who is 52 years old with burns to the lower extremities, what would a nurse include in the nursing plan?
|a.||Change the dressing using good medical asepsis|
|b.||Provide an analgesic immediately after the dressing change|
|c.||Perform circulation checks every 2 to 4 hours|
|d.||Keep the room temperature at 85° F (29.4° C) to prevent chilling|
- The nurse has staged a pressure ulcer that has a shallow crater with a dry pink wound bed as a:
- What would the nurse dressing a necrotic pressure ulcer with a minimal exudate most likely use?
- The nurse is caring for a 26-year-old male patient who was burned 72 hours ago. He has partial-thickness burns to 24% of his body surface area. He begins to excrete large amounts of urine. What should the nurse do?
|a.||Increase the IV rate and monitor for burn shock|
|b.||Monitor for signs of seizure activity.|
|c.||Assess for signs of fluid overload|
|d.||Raise the foot of the bed and apply blankets|
- A patient with severe eczema is starting a coal tar derivative treatment. What should the nurse include in the teaching plan for the patient relative to this treatment?
|a.||Drink at least 1000 mL of fluid daily|
|b.||Avoid exposure to sunlight for 72 hours after use|
|c.||Bathe with an astringent soap|
|d.||Reduce intake of high calcium foods|
- What should the nurse examine in assessing a patient for tinea corporis?
|a.||Soles of the feet|
- What is the initial intervention for relief of the pruritus of dermatitis venenata?
|a.||Apply baking soda to lesions|
|b.||Wash area with copious amounts of water|
|c.||Apply cool compresses continuously|
|d.||Expose area to air|
- The nurse debriding a burn wound explains that the purpose of debridement is to:
|a.||increase the effectiveness of the skin graft.|
|b.||prevent infection and promote healing.|
|c.||promote suppuration of the wound.|
|d.||promote movement in the affected area.|
- A patient has been admitted to the hospital with burns to the upper chest. The nurse notes singed nasal hairs. The nurse needs to assess this patient frequently for which condition?
- Which may indicate a malignant melanoma in a nevus on a patient’s arm?
|a.||Even coloring of the mole|
|b.||Decrease in size of the mole|
|c.||Irregular border of the mole|
|d.||Symmetry of the mole|
- A nurse can assess cyanosis in a dark-skinned patient by noting the color of the:
|c.||lips and mucous membranes.|
|d.||soles of the feet.|
- A patient developed a severe contact dermatitis of the hands, arms, and lower legs after spending an afternoon picking strawberries. The patient states that the itching is severe and cannot keep from scratching. Which instruction would be most helpful in managing the pruritus?
|a.||Use cool, wet dressings and baths to promote vasoconstriction.|
|b.||Trim the fingernails short to prevent skin damage from scratching.|
|c.||Expose the areas to the sun to promote drying and healing of the lesions.|
|d.||Wear cotton gloves and cover all other affected areas with clothing to prevent environmental irritation.|
- What is the best instruction by the nurse regarding reducing the risk factors for melanoma?
|a.||Avoid exposure to the sun and use protective measures when exposure occurs.|
|b.||Have all nevi removed.|
|c.||Watch for changes in moles, especially on the back.|
|d.||Use a sun lamp for tanning.|
- Which patient instruction should the nurse include in the teaching plan relative to the management of systemic lupus erythematosus?
|a.||Maintain a balance between rest and activity|
|b.||Increase activity to promote mobility|
|c.||Increase exposure to the sun to increase vitamin D absorption|
|d.||Increase sodium consumption|
- Which patient statement indicates that more teaching is needed regarding antibiotic therapy for the treatment of cellulitis?
|a.||”My skin is cleared up. I don’t think I need the medication anymore.”|
|b.||“Cellulitis can come back at any time.”|
|c.||“If I had washed that scratch with soap and water, I probably would not have gotten cellulitis.”|
|d.||”Cellulitis is contagious.”|
- What should a patient be assessed for upon the diagnosis of genital herpes?
|c.||Human immunodeficiency virus (HIV).|
- The school nurse recognizes the signs of scabies when a child presents with:
|a.||small fluid filled blisters that sting when scratched.|
|b.||dry scaly patches in body creases that itch.|
|c.||wavy threadlike lines on the body and pruritus.|
|d.||cluster of papular lesions with pruritus.|
- Melanocytes give rise to the pigment melanin, which is responsible for skin color. Where can the melanocytes be found?
|d.||Loose connective tissue|
- Which of the following are major functions of the skin? (Select all that apply.)
|a.||Excretion of wastes|
|c.||Vitamin C synthesis|
|e.||Prevention of dehydration|
- During primary survey assessment of a burn patient, the nurse checks for which of the following as early signs of carbon monoxide poisoning? (Select all that apply.)
- What is a common diagnostic criterion for identifying systemic lupus erythematosus (SLE)? (Select all that apply.)
|a.||Butterfly rash over nose and cheeks|
|c.||Severe abdominal pain|
|e.||Polyarthralgias and polyarthritis|
- Which of the following are nursing interventions and patient teaching for the treatment of head lice and scabies? (Select all that apply.)
|a.||Clothing, linens, and bath articles thoroughly cleaned in hot water|
|b.||Stress nature and transmission of the disease|
|c.||Special carbohydrate diet to promote healing|
|d.||Complete isolation from the public|
- The most deadly skin cancer is ________________.
- The three major glands of the skin are __________, ___________, and __________.
- The nurse making the initial assessment of a burned patient in the emergency room observes that the entire right arm (anterior and posterior), right anterior leg, chest, and abdomen are covered with reddened skin and blisters. Using the Rule of Nines, the nurse estimates the percentage of burn to be______%.
- Prioritize the intervention of the first responder to the victim during the emergent phase of burn management. (Separate letters by a comma and space as follows: A, B, C, D.)
- Transport victim to hospital.
- Cover victim with clean cloth or sheet.
- Stop, drop, and roll.
- Remove all nonadherent clothing and jewelry.
- Provide an open airway.
- Control any bleeding.
- Prioritize the interventions for a hospitalized severely burned victim during the emergent phase. (Separate letters by a comma and space as follows: A, B, C, D.)
- Tetanus prophylaxis
- Insert Foley catheter
- Insert nasogastric tube
- Establish airway
- Administer analgesics
- Initiate fluid therapy
Chapter 4: Care of the Patient with a Musculoskeletal Disorder
- What is the movement of an extremity away from the midline of the body called?
- What is the large, fan-shaped muscle that covers the anterior chest from the sternum to the proximal end of the humerus and acts on the joint of the shoulder to flex, adduct, and rotate?
- What should the nurse instruct the patient before a magnetic resonance imaging (MRI) procedure?
|a.||Void to completely empty the bladder|
|b.||Omit all citrus food for 12 hours before the procedure|
|c.||Remove all metal, such as jewelry, glasses, and hair clips|
|d.||Wear only cotton garments for the procedure|
- The nurse instructs the patient who is to have a unicompartmental knee replacement that a major advantage of this partial knee replacement is that:
|a.||the patient will be up and walking 2 to 3 hours after the operation.|
|b.||the kneecap is completely removed.|
|c.||the procedure is especially helpful in the treatment of rheumatoid arthritis.|
|d.||a small titanium disk replaces the worn cartilage.|
- A patient who has had a right below the knee amputation continues to complain of unpleasant sensation in the right foot. What can the nurse explain about this “phantom pain”?
|a.||It only exists in the mind.|
|b.||It is a complication following an amputation and can be clarified by the surgeon.|
|c.||It is related to the severed nerves that are still sending messages to the brain.|
|d.||It occurs when the person becomes focused on the loss of the limb.|
- The patient that has a bipolar hip replacement following an intracapsular fracture has an order to be turned every 2 hours. The nurse understands that the correct nursing intervention is to keep the legs:
|a.||together so they do not separate while turning.|
|b.||flexed to stabilize the prosthesis.|
|c.||abducted so the prosthesis does not become dislocated.|
|d.||adducted to prevent additional pain for the patient with turning.|
- A patient has been casted to stabilize a fracture of the right radius and ulna. The nurse assesses a capillary refill of 5 seconds and cold fingers of the right hand. Which initial intervention should the nurse deploy?
|a.||Notify the charge nurse of a probable compartment syndrome|
|b.||Apply a warm compress to the fingers to relieve swelling|
|c.||Elevate the right hand to heart level to maintain arterial pressure|
|d.||Cut the cast off to release constriction|
- A patient had an open reduction with internal fixation (ORIF) for a compound fracture of the left tibia and has been placed in a long leg cast. The assessments by the nurse are: left foot warm/pink, pedal pulse weaker than right, capillary refill 3 seconds, and small 1 cm area of blood on cast. What should the nurse do?
|a.||Notify charge nurse of impending compartment syndrome|
|b.||Document that all assessments are within normal limits|
|c.||Inform charge nurse about probable hemorrhage|
|d.||Place warm compresses on left foot|
- When a patient recovering from a fractured tibia asks what callus formation is, the nurse tells her it is:
|a.||when blood vessels of the bone are compressed.|
|b.||a part of the bone healing process after a fracture when new bone is being formed over the fracture site.|
|c.||the formation of a clot over the fracture site.|
|d.||when the hematoma becomes organized and a fibrin meshwork is formed.|
- Which patient statement indicates the need for additional teaching for a patient with rheumatoid arthritis who is taking meloxicam (Mobic)?
|a.||“I am keeping a daily record of my blood pressure.”|
|b.||“I take aspirin before I go to bed.”|
|c.||“I know I can take meloxicam with or without regard to meals.”|
|d.||“I weigh every day so I will be aware of any weight gain.”|
- What should the nurse include in the plan of care for a patient following a myelogram?
|a.||Position in a semi-Fowler position for 8 hours to reduce potential of headache|
|b.||Place patient flat on back to compress puncture site|
|c.||Ambulate for brief periods to lessen postmyelogram headache|
|d.||Limit fluids to increase absorption of the dye|
- Which finding would delay a computed tomography (CT) scan?
|a.||Patient’s allergy to shellfish|
|b.||Patient in first trimester of a pregnancy|
|c.||Patient’s allergy to milk products|
|d.||Patient’s gluten intolerance|
- Forty-eight hours after a patient sustained a fractured femur in a car accident, the nurse assessed a pulse of 110, respirations at 25, and labored crackles in both lung fields. The nurse immediately reports to the charge nurse the probability of a(n):
- What is the first priority nursing intervention for an impending fat embolism?
|a.||Administer oxygen in a respiratory emergency|
|b.||Increase intravenous fluids|
|c.||Position in flat position to ease decreased blood pressure|
|d.||Cover with warm blanket|
- A patient, age 68, has suffered an intertrochanteric fracture of the right hip. Before surgery, to provide support and comfort, an immobilizing device of a ______ is applied.
- Which foods should the home health nurse suggest for the patient with osteoporosis to help slow the disease?
|a.||Leafy green vegetables|
|b.||Foods high in sodium|
|c.||Tea and coffee|
- What should the nurse include in the teaching plan for a patient who is taking alendronate (Fosamax)?
|a.||Take drug with any meal|
|b.||Take drug first thing in the morning|
|c.||Drink at least 5 oz of milk before taking drug|
|d.||Take drug with an antacid to avoid heartburn|
- The patient has been diagnosed as having gouty arthritis. The patient asks the nurse to explain the cause of the inflammation of the great toe. What is the most appropriate nursing response?
|a.||“You have calcium oxalate deposits that are seen in gouty arthritis.”|
|b.||“The inflammation is from small accumulations of uric acid crystals, which are called tophi.”|
|c.||“The small nodules are not related to the arthritis condition.”|
|d.||“You have fat deposits that are common with gouty arthritis.”|
- When the patient with rheumatoid arthritis complains about the daily exercise, the nurse encouragingly reminds the patient that exercises:
|a.||keeps the joints from “freezing.”|
|b.||will ensure better sleep.|
|c.||should be vigorous for joint stimulation.|
|d.||need not be done daily.|
- The nurse clarifies to a patient who is being evaluated for possible rheumatoid arthritis that the elevated erythrocyte sedimentation rate indicates the presence of:
|b.||abnormal serum protein.|
|c.||increased inflammatory reaction in the body.|
- What should the nurse instruct the patient before the initiation of the antimalarial drug hydroxychloroquine (Plaquenil)?
|a.||Get a complete blood count to assess anemia.|
|b.||Get a chest x-ray.|
|c.||Get an eye examination.|
|d.||Take prophylaxis for malaria.|
- What should the nurse do when a patient with osteomyelitis is admitted with an open wound that is draining?
|a.||Enforce a low calorie diet|
|b.||Initiate drainage and secretion precautions|
|c.||Frequently do passive ROM on the elbow|
|d.||Ambulate several times daily|
- A 16-year-old male patient presents in the emergency room with a pathologic fracture of the left femur and complains of pain on weight bearing. These are cardinal indicators of:
- The 14-year-old boy who is scheduled for left leg amputation says to the nurse, “What in the world am I going to do with only one leg?” What is the nurse’s most therapeutic response?
|a.||“What are you thinking about right now?”|
|b.||“With a prosthesis, you will be as good as new.”|
|c.||“It is way too early to be concerned about that now.”|
|d.||“When my brother had his leg removed, he did great!”|
- A patient has undergone a bipolar hip repair (hemiarthroplasty). Which is the most appropriate instruction?
|a.||Sit in whatever position is most comfortable|
|b.||Sit in a firm, straight-backed chair at a 90-degree angle|
|c.||Avoid crossing the legs|
|d.||Begin full weight bearing as soon as tolerated|
- The nurse explains to a patient who has had a knee replacement that warfarin (Coumadin) is ordered to:
|a.||increase the red blood cells.|
|b.||reduce the threat of hemorrhage.|
|c.||prevent formation of emboli.|
|d.||help stabilize the prosthesis.|
- What should the nurse stress to a post–hip replacement patient in quadriceps setting exercises?
|a.||Push knee down to mattress and raise heel off the bed|
|b.||Flex knee and extend foot|
|c.||Adduct leg and flex foot|
|d.||Lift leg and heel off the bed|
- What should the home health nurse include assessment for in the plan of care for an 82-year-old female with severe kyphosis from ankylosis?
- What should the nurse stress to a patient who has had a hip replacement and is beginning strengthening exercises for the unaffected leg?
|a.||Flex the knee and flex the foot|
|b.||Lift the leg from the mattress and rotate the foot|
|c.||Pull knee to chest and extend the foot|
|d.||Push foot down against the footboard for a count of five|
- The office nurse has noted the presence of an increase in lumbar curvature in a 20-year-old female patient. What is this condition known as?
- How is rheumatoid arthritis distinguished from osteoarthritis?
|a.||Rheumatoid arthritis is an autoimmune, systemic disease; osteoarthritis is a degenerative disease of the joints.|
|b.||Rheumatoid arthritis is an autoimmune, degenerative disease; osteoarthritis is a systemic inflammatory disease.|
|c.||People with osteoarthritis are considered to be genetically predisposed; there is no known genetic component to rheumatoid arthritis.|
|d.||Osteoarthritis is often caused by a virus; viruses play no part in the pathogenesis of rheumatoid arthritis.|
- Which patient is most likely to develop osteoporosis?
|a.||43-year-old African American woman|
|b.||57-year-old white woman|
|c.||48-year-old African American man|
|d.||62-year-old Latino woman|
- The patient, age 58, is diagnosed with osteoporosis after densitometry testing. She has been menopausal for 5 years and has been concerned about her risk for osteoporosis because her mother has osteoporosis. In teaching her about her osteoporosis, which information does the nurse include?
|a.||Even with a family history of osteoporosis, the calcium loss from bones can be slowed by increased calcium intake and exercise.|
|b.||Estrogen replacement therapy must be started to prevent rapid progression of her osteoporosis.|
|c.||With a family history of osteoporosis, there is no way to prevent or slow bone reabsorption.|
|d.||Continuous, low-dose corticosteroid treatment is effective in stopping the course of osteoporosis.|
- Certain foods may increase the pain associated with gout. Which foods have the highest concentration of purines?
|a.||Brain, liver, kidney|
|b.||Lettuce, corn, potatoes|
|c.||Beef, pork, chicken|
|d.||Fruits and fruit juices|
- In order for a patient to flex the lower leg, which muscle must be contracted?
- Calcium is a mineral found in many foods that can slow bone loss during the aging process. Which food is high in calcium?
- A 56-year-old female patient is being seen for osteoarthritis of the knee in the clinic. What should the nurse recommend when discussing strengthening exercises?
|b.||Walking rapidly on a treadmill|
- What does prolonged bed rest put the older adult at risk for?
- Which of the following are the main purposes of traction? (Select all that apply.)
|a.||Align and stabilize a fracture|
|c.||Relieve muscle spasms|
|d.||Promote bed rest|
|e.||Increase circulation to the rest of the body|
- The characteristics of osteoarthritis that should be included in a teaching plan would include that osteoarthritis (select all that apply):
|a.||will cause the formation of Heberden nodes.|
|b.||can involve other organs.|
|c.||results from wear and tear.|
|d.||may affect only one side of the body.|
|e.||may cause constitutional symptoms of fatigue and fever.|
|f.||will cause marked erythema and edema of hands.|
- What are the three vital functions muscles perform when they contract? (Select all that apply.)
|a.||Absorb uric acid|
|b.||Maintenance of posture|
|e.||Production of heat|
|f.||To assist in return of venous blood to the left side of the heart|
- Which instructions should the nurse include in a teaching plan for a person with gouty arthritis? (Select all that apply.)
|a.||Avoid excessive alcohol.|
|b.||Maintain rest and immobility while disease is symptomatic.|
|c.||Check urine and urine output for possible kidney stones.|
|d.||Include food high in purine in the diet.|
|e.||Use bed cradle to support linens.|
- The division of the skeletal system that comprises the skull, hyoid, vertebral column, and thorax is the _____________ division.
- A patient’s patellar-femoral cartilage has deteriorated due to arthritis. The medial and lateral cartilage is undamaged. This patient is likely to undergo _________ knee replacement surgery.
- The emergency department nurse assesses the two cardinal signs of a hip fracture in a newly admitted patient, which are the___________ of the injured leg and the ______rotation of that same leg.
- The nurse administering the drug colchicine for gout will give 0.5 mg hourly for _____ hours.
- The nurse explains that the use of the _________brace allows a person with a cervical fracture to be mobile.
- The nurse takes into consideration that a healing fracture progresses through several healing stages. Place the stages in order of healing. (Separate letters by a comma and space as follows: A, B, C, D)
- Development of fibrin meshwork
- Collagen fibers collect calcium
- Osteoblasts home fracture site form
- Formation of hematoma
- Clot formation
Chapter 5: Care of the Patient with a Gastrointestinal Disorder
- The nurse clarifies that the end product of carbohydrate metabolism is absorbed and put into the blood stream by the:
|a.||gastric lining of the stomach.|
|b.||villi of the small intestine.|
|c.||bile of the liver in the large intestine.|
|d.||excretion from the cecum.|
- A 56 -year-old man is admitted to the emergency room with an acute attack of diverticulitis. The patient has a temperature of 102° F, and has an elevated white count. Which assessment would alert the nurse to impending septic shock?
- Because bowel contents from an ileostomy are virtually liquid, what should the nurse include in the plan of care?
|a.||Evaluation and assessment of dietary intake of fiber|
|b.||Evaluation and assessment of patient cleanliness|
|c.||Evaluation and assessment of periostomal skin integrity|
|d.||Evaluation and assessment of the adequacy of the collection device|
- The home health nurse caring for a patient who has dysarthria related to radiation therapy for an oral cancer would recommend that the family provide:
|a.||a tablet and pencil as a communication aid.|
|b.||a TV for diversion.|
|c.||a bell to summon help.|
- Which recommendation is most appropriate for a patient who has had an esophageal dilation related to achalasia?
|a.||Consume only liquid|
|b.||Avoid fruit juices|
|c.||Drink 10 oz of fluid with each meal|
|d.||Lie down for 30 minutes after each meal|
- A patient who is being evaluated for episodes of hematemesis and dyspepsia tells the nurse that pain occurs when he eats, but pain does not waken him. The nurse recognizes a diagnostic sign of which condition?
- The nurse anticipates that the patient who has had a subtotal gastrectomy will need supplemental:
|a.||protein due to the loss of some of the digestive processes.|
|b.||vitamin B12 due to the loss of the intrinsic factor.|
|c.||bulk to prevent constipation.|
|d.||vitamin A due to the loss of the gastric lining.|
- The home health nurse is caring for a patient who has frequent bouts of diverticulitis accompanied by increased flatulence, diarrhea, and nausea. Which of the following is the most appropriate suggestion to lessen these symptoms?
|a.||Eat a diet high in fiber content|
|b.||Increase dietary fat intake|
|c.||Exercise to increase intra-abdominal pressure|
|d.||Take daily laxatives|
- The nurse caring for a patient with a peptic ulcer who has had a nasogastric tube inserted notes bright blood in the tube; the patient complains of pain and has become hypotensive. Which condition should the nurse recognize these as signs of?
- Dumping syndrome after a Billroth II procedure occurs when high-carbohydrate foods are ingested over a period of less than 20 minutes. What would the nurse suggest to reduce the risk of dumping syndrome?
|a.||Eating a high-carbohydrate diet|
|b.||Drinking 10 oz of fluids with meals|
|c.||Remaining upright for 2 hours after meals|
|d.||Eating six small daily meals high in protein and fat|
- The patient has come to the PACU following an ileostomy for the treatment of ulcerative colitis. The patient is conscious and has a nasogastric tube in place and a pouch over the stoma. What should be the nurse’s initial action?
|a.||Turn patient to right side|
|b.||Give patient ice chips to moisten mouth|
|c.||Attach NG tube to suction|
|d.||Irrigate NG tube|
- The home health nurse evaluates a patient being treated for a peptic ulcer with Riopan (antacid) and famotidine (histamine receptor blocker). Which statement made by the patient indicates a need for further instruction?
|a.||“I know famotidine will not interfere with my Coumadin.”|
|b.||“I take the Riopan at least 2 hours after any of my other drugs.”|
|c.||“Boy! That Riopan keeps my stomach happy!”|
|d.||“I take both those meds at the same time every morning.”|
- What should a nurse do when obtaining a stool specimen to be examined for ova and parasites?
|a.||Use an oil retention enema to facilitate collection|
|b.||Refrigerate the specimen immediately|
|c.||Obtain three different stool specimens on subsequent days|
|d.||Check the specimen for the presence of occult blood|
- The nurse explains to the patient with Crohn disease that the tube feedings allow for:
|a.||Rapid absorption in the upper GI tract|
|b.||Decompression of the stomach|
|c.||Reduction of diarrheic episodes|
|d.||A permanent nutritional support|
- A patient with a large inguinal hernia has abdominal distention and inguinal pain. The nurse recognizes these as indicators of which type of hernia?
- A patient with a ruptured diverticulum in the descending colon has undergone a transverse loop colostomy. The patient is upset and says, “I didn’t know it was going to be this awful. I hate this!” Which response made by the nurse would be most helpful?
|a.||“This is a temporary solution. It will be closed in 6 weeks.”|
|b.||“This seems awful now, but you won’t have the problems you had before.”|
|c.||“If everything goes well the surgeon can close this colostomy in about a year.”|
|d.||“With the appropriate pouch and loose clothing, no one will notice a thing.”|
- A male patient complains that he will never adjust to his colostomy. Which is the best action for the nurse in this situation?
|a.||Encourage him to express his concern|
|b.||Suggest that he discuss his concerns with his physician|
|c.||Counsel him that everything will be all right|
|d.||Assure him that his concerns will diminish when he is able to care for his colostomy|
- In caring for a patient with gastric bleeding who has a nasogastric tube in place, the nurse should include in the plan of care to ensure that the NG tube is:
|a.||Clamped for 10 minutes every hour|
|b.||Kept patent with irrigation|
|c.||Frequently repositioned to the opposite nostril|
|d.||Changed every 72 hours|
- What should the nurse include in a teaching plan for a patient with a hiatal hernia to reduce the frequency of heartburn?
|a.||Drinking 10 oz of milk with every meal|
|b.||Lie down after eating|
|c.||Panting through mouth when symptoms begin|
|d.||Eating small meals|
- The nurse points out which of the following as an example of a nonmechanical bowel obstruction?
|a.||A paralytic ileus|
|b.||Narrowed bowel lumen from an inflammatory process|
|c.||Tumor of the bowel|
- Bowel sound assessment on a patient with an obstruction who has distention, nausea, and visible peristaltic waves would be:
|a.||loud and clearly audible.|
- The patient with a peptic ulcer has been placed on regular doses of bismuth salicylate (Pepto-Bismol) to combat H. pylori. What color will this drug turn the stool?
- Which of the following should be included in the patient teaching of a patient with a peptic ulcer?
|a.||Introducing irritating foods in minute amounts to desensitize the stomach|
|b.||Restricting fluid to 1000 mL per day|
|c.||Eating 6 small meals a day|
|d.||Drinking alcohol and caffeine in moderation|
- Which of the following would be the most helpful nursing intervention to increase the comfort of a patient with appendicitis?
|a.||Application of ice bag|
|b.||Administration of small tap water enema|
|c.||Warm compress over entire abdomen|
|d.||Ambulate for short periods in the room|
- To assist a family with a bowel training program to reduce fecal incontinence, the nurse would suggest the use of a ___________ at an optimal time to stimulate defecation.
|b.||A tap water enema|
|d.||Large glass of warm lemonade|
- What is the most lethal complication of a peptic ulcer?
|d.||Gastric outlet obstruction|
- The nurse takes into consideration that a proton pump inhibitor drug, such as ______________, will completely eradicate gastric acid production.
- Which of the following is the purpose of antibiotic therapy in treating peptic ulcers?
|a.||It eradicates H. pylori|
|b.||It inhibits gastric acid secretion|
|c.||It protects the gastric mucosa|
|d.||It neutralizes or reduces the acidity of stomach contents|
- Why are peptic ulcers a common problem of aging?
|a.||Because of overuse of antibiotics|
|b.||Because of overuse of antacids|
|c.||Because of overuse of NSAIDs|
|d.||Because of overuse of laxatives|
- The patient with irritable bowel syndrome tells the home health nurse she is going to an acupuncturist for therapy for her condition. Which of the following would be the best
|a.||“Go for it. Alternative medicine does great things.”|
|b.||“YIKES! An acupuncturist?”|
|c.||“It may help, but there has been no clinical proof of its effectiveness.”|
|d.||“You should confirm that the acupuncturist is licensed.”|
- Which of the following are indicators of colorectal cancer? (Select all that apply.)
- How should the nurse counsel the 34-year-old woman who has been prescribed sulfasalazine (Azulfidine) for Crohn disease? (Select all that apply.)
|a.||Expose her to sunlight at least 30 minutes a day for vitamin D synthesis|
|b.||Tell her to drink at least 1500 mL of fluid a day|
|c.||Advise assessing self for rash|
|d.||Use alternate birth control methods to oral contraception|
|e.||Take drug on an empty stomach|
- In designing a teaching plan to present to a group of older adults regarding the prevention of esophageal cancer, the nurse would include information about the significance of (select all that apply):
|a.||cessation of smoking.|
|b.||good oral care.|
|c.||regular checkups if dysphagia is present.|
|d.||reducing excessive weight.|
|e.||limiting alcohol consumption.|
|f.||reduction of consumption of citrus fruits.|
- Which activities should the home health nurse suggest to an elderly patient to avoid constipation? (Select all that apply.)
|a.||Increasing physical activity|
|b.||Taking bulk-forming laxatives|
|c.||Increasing fiber intake|
|d.||Drinking at least 1000 mL fluid|
|e.||Taking a daily stool softener|
|f.||Using tap water enemas for persons with altered mobility|
- The home health nurse is caring for a patient who has frequent abdominal pain and diarrhea. The nurse uses the Rome Criteria to direct assessment for irritable bowel syndrome. What is included in the Rome Criteria? (Select all that apply.)
|a.||Discomfort at least 3 days a month|
|b.||Blood in stool|
|c.||Pain relieved by defecation|
|e.||Nausea and vomiting associated with onset|
|f.||Onset associated with change in stool consistency or frequency|
- Flexible sigmoidoscopy should be performed every ________ years.
- The nurse explains that ___________, the chief enzyme of gastric juice, is activated by hydrochloric acid to begin digestion of protein.
- The nurse caring for a patient with Crohn disease will closely monitor the urinary output to ensure that the patient is excreting at least _______mL/day.
- The nurse takes into consideration that long-term use of antibiotics can cause an antibiotic-associated pseudomembranous colitis from the organism________.
- Due to frequent bouts of constipation, the nurse examines the bedfast nursing home resident for ulceration of the anus, called __________________.
- The nurse uses a poster to show the process of bowel obstruction from diverticulitis. Arrange the pathophysiologic event in order. (Separate letters by a comma and space as follows: A, B, C, D)
- Increase in intra-abdominal pressure
- Weakened wall of sigmoid
- Pouch fills with fecal matter
- Pouch protrudes through smooth muscle
- Narrowing of bowel lumen
- Inflammation of diverticula
- Celiac sprue in the adult can lead to systemic problems. Arrange the pathophysical events of this in order of their appearance. (Separate letters by a comma and space as follows: A, B, C, D)
- Weight loss/vitamin deficiency
- Systemic involvement
- Ingestion of gluten
- Destruction of villi in the small intestine
Chapter 6: Care of the Patient with a Gallbladder, Liver, Biliary Tract, or Exocrine Pancreatic Disorder
- The nurse clarifies that unconjugated bilirubin, which is made up of broken-down red cells, is:
|a.||stored in the gallbladder to make bile.|
|b.||water insoluble bilirubin that must be converted by the liver.|
|c.||a by-product which is excreted directly into the bowel for excretion.|
|d.||necessary for digestion of fats.|
- The patient with cirrhosis has an albumin of 2.8 g/dL. The nurse is aware that normal is 3.5 g/dL to 5 g/dL. Based on these findings, what would the nurse expect the patient to exhibit?
|c.||Copious urine output|
- What is an essential nursing measure to prevent injury to the patient who is to receive a paracentesis?
|a.||Have patient sign a permit|
|b.||Pad side rails|
|c.||Check for allergy to contrast media or to shellfish|
|d.||Have patient void immediately before procedure|
- What should the nurse expect of a patient with a malabsorption of vitamin K?
|c.||Increased prothrombin time|
|d.||Diminished white blood cell count|
- A patient was scheduled for a laparoscopic cholecystectomy, but complications developed and he underwent an open cholecystectomy with a T-tube inserted into the common bile duct. What is the purpose of the T-tube?
|a.||To decompress the duct and relieve pain caused by stimulation of the sphincter of Oddi.|
|b.||To improve diaphragmatic expansion and prevention of atelectasis.|
|c.||To shorten postoperative recovery and hasten the healing process.|
|d.||To keep the duct open and allow drainage of the bile until edema resolves.|
- The nurse caring for a patient who has had an open cholecystectomy with a T-Tube will:
|a.||open the T-tube to the air so that it will drain freely.|
|b.||position and secure the drainage bag at the chest level.|
|c.||Place the collection bag so the tube is not kinked.|
|d.||Irrigate the T-tube with normal saline to ensure the free flow of bile.|
- Which nursing intervention should be completed immediately after the physician has performed a needle liver biopsy?
|a.||Assisting to ambulate for the bathroom|
|b.||Keeping the patient on the right side for a minimum of 2 hours|
|c.||Taking vital signs every 4 hours|
|d.||Keeping the patient on the left side for a minimum of 4 hours|
- Immediately following a liver biopsy, the patient becomes dyspneic, the pulse increases to 100, and no breath sounds can be heard on the affected side. What should the nurse suspect?
|c.||Hemorrhage of the liver|
- Which patient statement indicates that the patient requires additional teaching about an endoscopic retrograde cholangiopancreatography?
|a.||“Right after the test, I want breakfast with black coffee.”|
|b.||“The instrument will be put down my throat.”|
|c.||“I haven’t had anything to eat or drink since 9 PM last night.”|
|d.||“My doctor said I could have medicine to relax me before the test.”|
- The nurse assisting in the treatment of a patient with ruptured esophageal varices who has received vasopressin IV will carefully assess for:
|c.||Macular rash on trunk and arms|
|d.||Evidence of cardiac ischemia|
- What should the nurse point out as a significant advantage of the laparoscopic cholecystectomy?
|a.||Slightly more invasive, but there is less pain|
|b.||Can be performed on all patients of any age|
|c.||Can be performed even when there are large stones present in the bile duct|
|d.||Less invasive procedure|
- What should the nurse explain is the major purpose of the Sengstaken-Blakemore tube (S/B tube)?
|a.||Decompress the stomach|
|b.||Control esophageal varices bleeding|
|c.||A route for tube feedings|
|d.||Obtain specimen for gastric analysis|
- The patient’s cirrhosis of the liver has also caused a dilation of the veins of the lower esophagus secondary to portal hypertension, resulting in the development of the complication of:
|d.||esophageal reflux (GERD).|
- The patient with cirrhosis has a rising ammonia level and is becoming disoriented. The patient waves to the nurse as she enters the room. How should the nurse interpret this?
|a.||As an attempt to get the nurse’s attention|
|c.||As an indication of respiratory obstruction from varices|
- How does the administration of neomycin (Mycifradin) reduce the production of ammonia?
|a.||By assisting the hepatic cells to regenerate|
|b.||By reducing ascites|
|c.||By decreasing the bacteria in the gut|
|d.||By helping to digest fats and proteins|
- What is the most common procedure for the removal of the gallbladder?
- What should the nurse do to prepare a patient for an oral cholecystography?
|a.||Ensure that the patient drinks 500 mL of water before testing|
|b.||Give 4 Oragrafin (ipodate) 5 minutes apart starting at 6 AM|
|c.||Administer 6 Telepaque (iopanoic acid) tablets 5 minutes apart after the evening meal|
|d.||Give a fatty meal hour before the test is started|
- Which of the following is a classic symptom of cholecystitis?
|a.||Substernal, radiating to the left shoulder and arm|
|b.||Epigastric, radiating to the back|
|c.||Right upper abdomen, radiating to the back or right scapula|
|d.||Left upper abdomen, radiating to the jaw and neck|
- What should the nurse avoid contamination from to prevent the transmission of hepatitis A?
|a.||Food or water|
- What is the most appropriate method used by high-risk health workers to prevent hepatitis B?
|a.||Hepatitis B vaccine|
|c.||Wearing protective gear|
|d.||Hb immune globulin injections|
- The nurse explains that the use of cyclosporine as an immunosuppressant has been successful in the reduction of rejection of liver transplants because the drug:
|a.||increases the rate of the regeneration of liver cells.|
|b.||can overcome complications presented by hepatitis C.|
|c.||increases blood supply to transplant.|
|d.||does not suppress bone marrow.|
- A male patient states that he returned from a 2-week camping trip a few days ago. He complains of nausea and anorexia, and dark urine. What additional information would assist in diagnosing hepatitis A?
|a.||Exposure to blood|
|b.||Recent ingestion of raw fish|
|c.||History of intravenous drug use|
|d.||Multiple sex partners|
- When caring for an extremely jaundiced patient with cirrhosis, what should the nurse include provisions for in the plan of care?
|a.||Encouraging consumption of a high-fat diet|
|b.||Skin care to relieve pruritus|
|c.||Offering foods rich in fat-soluble vitamins|
|d.||Meticulous foot care|
- The nurse is aware that an elevated serum amylase is diagnostic of pancreatitis at an early stage as an elevation can be assessed as early as _____ after the onset of pancreatic disease.
- The 100 lb patient who has been exposed to hepatitis A is to receive an injection of immune serum globulin. What should the dose (.02 mL/kg) be?
- A family member of a patient asks the nurse about the protein-restricted diet ordered because of advanced liver disease with hepatic encephalopathy. What statement by the nurse would best explain the purpose of the diet?
|a.||“The liver cannot rid the body of ammonia that is made by the breakdown of protein in the digestive system.”|
|b.||“The liver heals better with a high-carbohydrate diet rather than with a diet high in protein.”|
|c.||“Most people have too much protein in their diets. The amount in this diet is better for liver healing.”|
|d.||“Because of portal hypertension, the blood flows around the liver, and ammonia made from protein collects in the brain, causing hallucinations.”|
- The nurse would make provisions in the plan of care for a person who has had a liver transplant to prevent:
- The nurse is aware that the hepatitis A immunization provides immunity in:
- What is the challenge in encouraging coughing and deep breathing for a postoperative patient who had an open cholecystectomy?
|a.||High placement of incision|
|c.||Weakened abdominal muscles|
- Why is it advantageous for a live person to be a liver donor?
|a.||Because the donor is not at risk for any complication|
|b.||Because the recipient is more likely to avoid rejection|
|c.||Because the donor donates only a part of the liver|
|d.||Because the blood supply is more dependable in the donated liver|
- Which factors are most commonly associated with pancreatitis?
|a.||Coronary artery disease|
|b.||Alcoholism and biliary tract disease|
|d.||History of myocardial infarction|
- A patient with pancreatitis is NPO. The patient asks the nurse why he is unable to have anything by mouth. Which of the following is the best response?
|a.||“Diagnostic tests depend on you not eating anything.”|
|b.||“The pancreas is stimulated whenever you eat or drink, and causes pain.”|
|c.||“Eating causes the need for a bowel movement, which excretes your medication too rapidly.”|
|d.||“Resting your GI tract will cure your pancreatitis.”|
- Why is morphine contraindicated in the patient with pancreatitis?
|a.||Demerol (meperidine) is less expensive.|
|b.||Tylenol is more effective at managing this type of pain.|
|c.||Morphine may cause spasms of the sphincter of Oddi.|
|d.||These patients do not experience pain.|
- Which factors may increase a patient’s risk of developing cancer of the pancreas?
|a.||Diet high in carbohydrates and dairy products|
|b.||Cardiovascular disease and glaucoma|
|c.||Tea and cola consumption|
|d.||Cigarette smokers and people with diabetes mellitus|
- Which assessment would indicate possible gallbladder disease in an older adult?
|a.||Dull pain in the right upper quadrant region|
|b.||Changes in color of urine or stool|
|c.||Distention of veins in upper part of body|
|d.||Aching muscles and tenderness in the liver|
- What should the nurse monitor in caring for the patient undergoing a paracentesis?
|a.||The urinary output|
|c.||Fluid removal over at least 30 minutes|
- A patient with a T-tube for an open cholecystectomy has resumed oral intake. The T-tube is clamped 2 hours before meals and unclamped 2 hours after meals to aid in the digestion of fat. During the time the tube is clamped the patient complains of abdominal pain and nausea. Which intervention is most appropriate?
|a.||Notify the physician|
|b.||Unclamp the tube immediately|
|c.||Increase the IV fluids|
|d.||Change the T-tube dressing|
- What are the indications for a liver transplant? (Select all that apply.)
|a.||Congenital biliary abnormalities|
|d.||Cirrhosis due to alcoholism|
- Which medical interventions and management systems control the bleeding of esophageal varices? (Select all that apply.)
|f.||Large doses of vitamin B12|
- Dietary teaching for a patient who is treated conservatively for cholecystitis is necessary to keep the patient comfortable. Which foods should be avoided? (Select all that apply.)
|c.||Rice and pasta|
|d.||Bananas, apples, oranges|
|f.||Glazed chocolate doughnuts|
- Viral hepatitis may be treated at home. What should be taught to the patient’s family? (Select all that apply.)
|a.||Clothes should be laundered separately with hot water.|
|b.||Personal items and drinking glasses should not be shared.|
|c.||Articles soiled with feces do not require extra care.|
|d.||Hands need to be thoroughly washed after toileting.|
|e.||Contaminated items may be disposed of with regular trash.|
- The nurse is aware that the liver synthesizes products essential to health. Which products are synthesized by the liver? (Select all that apply.)
|d.||Red blood cells|
- What should the nurse do as part of the preparation for an endoscopic retrograde cholangiopancreatography (ERCP)? (Select all that apply.)
|a.||Confirm that a recent chest x-ray is on file|
|b.||Confirm the presence of a consent form|
|c.||Warn patient that the procedure will take about 3 hours|
|d.||Confirm the presence of a prothrombin time/INR|
|e.||Withhold food and drink for 4 hours|
- ___________ is a condition characterized by yellowing of the sclera and the skin.
- The disease that is on the increase because of the growing obesity population and is associated with coronary artery disease and use of corticosteroids is_______________.
- The tumor marker that is elevated in patients with pancreatic cancer is______.
- Hepatitis D is usually seen as a co-infection with __________.
- A ___________occurs when the body encapsulates the autodigestive debris in the pancreatic tissue, frequently becoming an abscess.
- The nurse clarifies that deterioration progresses through stages before presenting with liver disease. Place the stages in order. (Separate letters by a comma and space as follows: A, B, C, D)
- Liver disease
- Hepatic insufficiency
- Fibrotic regeneration
- Arrange the normal process of protein metabolism. (Separate letters by a comma and space as follows: A, B, C, D)
- Protein enters the blood stream
- Excreted by kidney
- Portal vein delivers blood to the liver
- Conversion to urea
- Ammonia produced in the bowel
Chapter 7: Care of the Patient with a Blood or Lymphatic Disorder
- What is the process by which certain cells engulf and digest microorganisms and cellular debris?
- The nurse explains that because it is a reliable and predictable indicator of the body’s level of infection or recovery the _____________________ is a common diagnostic tool.
|c.||Mean cell volume (MCV)|
- The nurse assessing a differential sees an increase in immature neutrophils (bands) and is aware that this indicates:
|a.||a significant hemorrhage.|
|c.||an overwhelming bacterial infection.|
|d.||beginning recovery from an infection.|
- B cells and T cells fit under which classification?
- The nurse explains that in the event of an invasion of an allergen, the basophils release a strong vasodilator, which is:
- The presence of excess bands in the peripheral blood that indicate severe infection is called:
|a.||shift to the left.|
|b.||shift to the right.|
|c.||bone marrow aspiration.|
- A patient who had a Schilling test shows a 20% excretion of the radioactive vitamin B12. What would this indicate?
|a.||The patient has a low reserve of iron and has iron deficiency anemia.|
|b.||The patient has a normal finding and does not have pernicious anemia.|
|c.||The patient has a deficiency of thrombocytes and has a clotting disorder.|
|d.||The patient has an excess of RBCs and has polycythemia.|
- In an adult, where are erythrocytes continuously produced?
|a.||Yellow bone marrow|
|d.||Red bone marrow|
- What does the elevation in the eosinophil count to 10% indicate?
- What would a nurse include in a teaching plan for a home health patient with a hemoglobin of 8.4 mg?
|a.||Exercising for periods of 30 minutes daily|
|b.||Limiting fluid intake|
|c.||Alternating activity with rest periods|
|d.||Avoiding the use of oxygen|
- Approximately how much blood is stored in the spleen that can be released in a hypovolemic emergency?
- The nurse caring for a patient with pernicious anemia should make provisions for:
|a.||frequent iced drinks.|
|c.||a fan to circulate the air.|
TOP: Pernicious anemia
- When instructing the patient taking an oral liquid iron preparation, what should the nurse include?
|a.||Information relative to taking the iron with milk|
|b.||Information relative to the bowel movement color changing to dark red|
|c.||Information relative to taking preparation through a straw to prevent staining of teeth|
|d.||Information relative to taking a drug with meals or a snack|
- When the 14-year-old African American boy comes into the emergency room in sickle cell crisis, what should be the primary focus of care?
|a.||Instruct patient about transfusion procedure|
|b.||Starting of IV fluids|
|d.||Relief of dyspnea|
- The mother of a 4-year-old child with leukemia says to the nurse, “I don’t understand why he is crying about his legs hurting.” The nurse’s most informative response would be based on the information that bone pain is related to:
|a.||Elevated WBCs in differential|
|b.||Long periods of inactivity|
|d.||Bone marrow congested with white cells|
- What must a patient undergo before a bone marrow transplant?
|a.||A thorough nutritional plan to support new marrow|
|b.||Total body irradiation to kill all the marrow cells|
|c.||A physical therapy program to strengthen the body|
|d.||Inhalation therapy to reduce possible pathogens in the lungs|
- The 9-year-old child with leukemia who is on palliative care has drawn a picture of a boy under a huge black cloud that has lightning coming out of it. Which of the following would be an appropriate intervention for the nurse?
|a.||“What is this picture about?”|
|b.||“Are you afraid of lightning?”|
|c.||“I bet this is a picture of you, isn’t it?”|
|d.||“Is it about to rain in your picture?”|
- The home health nurse recommends to the mother of a 12-year-old child with leukemia that the child should have:
|a.||the series for prevention of hepatitis B.|
|b.||an annual influenza vaccine.|
|c.||an annual pneumococcal vaccine.|
|d.||vitamin B12 shots.|
- Which patient statement from a 15-year-old girl with thrombocytopenia would require more assessment to report to the charge nurse?
|a.||“I think these red spots on my skin are going away.”|
|b.||“I am so bored lying in bed I could scream.”|
|c.||“My bowel movement is brown and stinks.”|
|d.||“I have this really weird Coke-colored urine.”|
- A 23-year-old male patient with hemophilia A says, “How can I keep my children from having hemophilia A?” Which of the following is the most informative response?
|a.||“You need to select a very dependable mode of birth control.”|
|b.||“You can only pass hemophilia B to your sons.”|
|c.||“Your daughter may be a carrier and her children may have hemophilia A. Your son is not at risk.”|
|d.||“Your sons should have coagulation studies.”|
- The nurse caring for a child with hemophilia who is hospitalized with hemarthrosis should include which of the following in the plan of care?
|a.||Splint the affected leg to maintain anatomic alignment|
|b.||Apply warm compresses to reduce hemorrhage in the joint|
|c.||Use analgesia sparingly|
|d.||Encourage vigorous ROM exercises several times a day to keep knee flexible|
- In caring for a patient with multiple myeloma, what should the nurse include in the daily care?
|a.||Provisions for limiting fluid intake to less than 1000 mL/day|
|b.||Provisions for close supervision and assistance when ambulating|
|c.||Provisions for straining all urine|
|d.||Provisions for limiting use of an analgesic|
- The nurse is aware that a person with Hodgkin disease, who has two or more abnormal lymph nodes on the same side of the diaphragm and involvement of extranodal involvement on the same side of the diaphragm, would be in:
- The nurse explains that a positron emission tomography (PET) has been ordered to:
|a.||assess bone marrow depression.|
|b.||measure bone density.|
|c.||radiate and destroy diseased lymph nodes.|
|d.||measure lymph node response to therapy.|
- Which of the following foods would the nurse recommend to a person with iron deficiency anemia as an excellent meat source for erythropoiesis?
|a.||Dark meat of chicken|
- The peripheral smear is a diagnostic test that:
|a.||assesses the level of hemoglobin.|
|b.||measures antibody production.|
|c.||examines the shape and structure of RBCs.|
- The typical medical treatment of polycythemia vera involves repeated phlebotomies and medications such as busulfan (Myleran) in order to:
|a.||stimulate bone marrow.|
|b.||inhibit bone marrow activity.|
- Which of the following would the nurse explain as the most common type of leukemia that affects children?
|a.||Chronic lymphocytic leukemia ( CLL)|
|b.||Acute myeloid leukemia (AML)|
|c.||Acute lymphocytic leukemia (ALL)|
|d.||Chronic myeloid leukemia (CML)|
- The nurse is aware that persons of the Jehovah’s Witness faith accept which types of blood transfusions?
|a.||No type of blood transfusion|
|b.||Blood that has been blessed by their religious leader|
|c.||Transfusions only for persons who have not yet been baptized|
|d.||Autologous blood transfusions|
- Which mandatory practice is the most effective and significant nursing practice to prevent the spread of infection?
|a.||Strict and frequent handwashing by all people having contact with the patient|
|b.||Placement of patients in private rooms with high-efficiency particulate air (HEPA) filtration|
|c.||Administration of combinations of prophylactic antibiotics|
|d.||Creation of a “sterile” environment for the patient with the use of laminar airflow rooms|
- What is the average life span of an erythrocyte?
|d.||Up to several years|
- Because older adults suffer from conditions such as colonic diverticula, hiatal hernia, and ulcerations that can cause occult bleeding, the nurse should assess for symptoms of:
|b.||iron deficiency anemia.|
|c.||sickle cell anemia.|
- The nurse explains that the treatment of hemophilia A has been revolutionized with the advent of the use of:
|b.||large doses of testosterone.|
|c.||recombinant factor VIII.|
|d.||transfusion with packed red cells.|
- From which location would the bone marrow sample come in the aspiration of a 25-year-old patient?
|b.||Posterior superior iliac crest|
|c.||Posterior iliac crest|
- What are the most likely matches for a bone marrow transplant to a 10-year-old with leukemia? (Select all that apply.)
- The spleen is a highly vascularized organ located in the left upper quadrant of the abdominal cavity. What are the main functions of the spleen? (Select all that apply.)
|a.||Serve as reservoir for blood|
|b.||Destroy worn-out RBCs|
|d.||Responsible for development of T lymphocytes|
|e.||Continuously produce RBCs during lifetime|
- The nurse examines the complete blood count (CBC) to assess (select all that apply):
|b.||red cell count.|
|c.||differential white cell count.|
- Which of the following are necessary factors that support healthy erythropoiesis? (Select all that apply.)
|b.||Healthy bone marrow|
|c.||Adequate oxygen source|
- The nurse caring for a patient in the emergency room with suspected internal injuries will assess for hypovolemic shock, which is evidenced by (select all that apply):
|c.||slow bounding pulse.|
- Which of the following are “B” symptoms of a patient with Hodgkin disease? (Select all that apply.)
|d.||Weight gain from edema|
|f.||Persistent dry cough|
- _____________ are leukocytes that destroy and remove cellular waste, bacteria, and solid particles.
- The person with aplastic anemia is said to be _________________ because all three major blood elements (RBCs, WBCs, and platelets) are diminished or absent.
- The nurse clarifies that ____________ _______________ replaces iron stores needed for red blood cell production.
- Neutrophils release ______________, an enzyme that destroys certain bacteria.
- The Reed-Sternberg cell is the hallmark diagnostic indicator for _______________ __________.
- Arrange the process of hemostasis in sequence. (Separate letters by a comma and space as follows: A, B, C, D)
- Release of clotting factor from injured tissue
- Formation of thrombin
- Formation of fibrin
- Trapping of RBC and platelets
- Release of thromboplastin
- Outline the sequence of the process that stimulates the increase in the production of red blood cells. (Separate letters by a comma and space as follows: A, B, C, D)
- Kidneys release erythropoietic factor
- Increase in red blood cell production
- Enzyme stimulates red bone marrow
- Oxygen delivery increased to the tissues
- Oxygen delivery decreased to the tissues
f, Decrease in red blood cell production
Chapter 8: Care of the Patient with a Cardiovascular or a Peripheral Vascular Disorder
- The nurse is aware that the muscle layer of the heart, which is responsible for the heart’s contraction, is the:
- The nurse clarifies that the master pacemaker of the heart is the:
|b.||atrioventricular (AV) node.|
|c.||sinoatrial (SA) node.|
|d.||bundle of His.|
- The nurse is aware that the symptoms of an impending myocardial infarction (MI) differ in women because acute chest pain is not present. Women are frequently misdiagnosed as having:
- The nurse identifies the “LUBB” sound of the “LUBB/DUBB” of the cardiac cycle as the sound of the:
|a.||AV valves closing.|
|b.||closure of the semilunar valves.|
|c.||contraction of the papillary muscles.|
|d.||contraction of the ventricles.|
- A patient is admitted from the emergency department. The emergency department physician notes the patient has a diagnosis of heart failure with a New York Heart Association (NYHA) classification of IV. This indicates the patient’s condition as:
|a.||moderate heart failure.|
|b.||severe heart failure.|
|c.||congestive heart failure.|
|d.||negligible heart failure.|
- The nurse assesses that the home health patient has no signs or symptoms of heart failure, but does have a history of rheumatic fever and has been recently diagnosed with diabetes mellitus. The nurse is aware that using the American College of Cardiology and the American Heart Association (ACC/AHA) staging, this patient would be a:
- The nurse caring for a patient recovering from a myocardial infarct who is on remote telemetry recognizes the need for added instruction when the patient says:
|a.||“I can ambulate in the hallway with this gadget on.”|
|b.||“I always take off the telemetry device when I shower.”|
|c.||“My EKG is being watched by one of the nurses in CCU on the home unit.”|
|d.||“I am able to sleep just fine with this device on.”|
- The nurse assesses pitting edema that can be depressed approximately inch and refills in 15 seconds. The nurse would document this assessment as:
- What do dark or “cold” spots on a thallium scan indicate?
|a.||Tissue with adequate blood supply|
|c.||Areas of neoplastic growth|
|d.||Tissue that has inadequate perfusion|
- The nurse recognizes the echocardiogram report that shows an ejection factor of 42% as an indication of:
|a.||normal heart action.|
|b.||mild heart failure.|
|c.||moderate heart failure.|
|d.||severe heart failure.|
- The nurse takes into consideration that age-related changes can affect the peripheral circulation because of:
|a.||sclerosed blood vessels.|
- The nurse assessing a cardiac monitor notes that the cardiac complexes each have a P wave followed by a QRS and a T. The rate is 120. The nurse recognizes this arrhythmia as:
- After an influenza-like illness, the patient complains of chills and small petechiae in his mouth and his legs. A heart murmur is detectable. These are characteristic signs of:
|a.||congestive heart failure.|
- The nurse notes a run of three ventricular contractions (PVC) that are not preceded by a P wave. This particular arrhythmia can progress into:
|a.||atrial fibrillation and possible emboli.|
|b.||sinus tachycardia and syncope.|
|c.||ventricular tachycardia and death.|
|d.||sinus bradycardia and fatigue.|
- The nurse reminds the patient who is on Coumadin for the treatment of atrial fibrillation that the ideal is to maintain the international normalized ratio (INR) at between:
|a.||1 and 2.|
|b.||2 and 3.|
|c.||3 and 4.|
|d.||4 and 5.|
- What should a person with unstable angina avoid?
|b.||Eating red meat|
|c.||Swimming in warm pool|
- The elderly patient with angina pectoris says she is unsure how she should take nitroglycerin when she has an attack. The nurse’s most helpful response would be:
|a.||“Continue to take nitroglycerin sublingually at 5-minute intervals until the pain is relieved.”|
|b.||“If the pain is not relieved after three doses of nitroglycerin at 5-minute intervals, call your physician and come to the hospital.”|
|c.||“When nitroglycerin is not relieving the pain, lie down and rest.”|
|d.||“Use oxygen at home to relieve pain when nitroglycerin is not successful.”|
- The patient has been hospitalized for hypertensive episodes three times in the last months. While preparing the discharge teaching plan, the nurse assesses that he does not comply with his medication regimen. The nurse’s immediate course of action would be to:
|a.||reteach him about his medications.|
|b.||have a serious talk with him and his family about compliance.|
|c.||arrange for home visits after discharge.|
|d.||collect more information to identify his reasons for noncompliance.|
- What is the major cause of cardiac valve disease?
|b.||Long history of malnutrition|
- The patient has a total cholesterol of 190 with a high-density lipid (HDL) of 110 and a low-density lipid (LDL) of 80. The nurse’s reaction is one of:
|a.||satisfaction. This is good cholesterol control.|
|b.||determination. This is evidence that more instruction is necessary.|
|c.||inquiry. This needs to clarified as to the cause of noncompliance with the drug protocol.|
|d.||regret. This shows very poor cholesterol control.|
- A patient, age 72, was admitted to the medical unit with a diagnosis of angina pectoris. Characteristic signs and symptoms of angina pectoris include:
|a.||substernal pain that radiates down the left arm.|
|b.||epigastric pain that radiates to the jaw.|
|c.||indigestion, nausea, and eructation.|
|d.||fatigue, shortness of breath, and dyspnea.|
- A patient admitted to the emergency room with a possible myocardial infarction (MI) has reports back from the laboratory. Which laboratory report is specific for myocardial damage?
|b.||Elevated white count|
|c.||Elevated sedimentation rate|
|d.||Low level of sodium|
- The patient, age 26, is hospitalized with cardiomyopathy. While obtaining a nursing history from her, the nurse recognizes that the increased incidence of cardiomyopathy in young
adults who have minimal risk factors for cardiovascular disease is related to which factor(s)?
|c.||Vitamin B1 deficiencies|
- The patient has become very dyspneic, respirations are 32, and the pulse is 100. The patient is coughing up frothy red sputum. What should be the initial nursing intervention?
|a.||Lay the patient flat to reduce hypotension and the symptoms of cardiogenic shock.|
|b.||Place patient in side-lying position to reduce the symptoms of atrial fibrillation.|
|c.||Place patient upright with legs in dependent position to reduce the symptoms of pulmonary edema.|
|d.||Lay the patient flat and elevate the feet to increase venous return in cardiogenic shock.|
- The nurse caring for a patient recovering from a myocardial infarction (MI) teaches which method to avoid the Valsalva maneuver during a bowel movement?
|b.||Pursing the lips and whistling|
|c.||Taking a deep breath and holding it|
|d.||Breathing rapidly through the nose|
- The nurse reminds the patient that the National Heart, Lung, and Blood Institute recommends a lipid study every _________ years.
- During a health interview by the home health nurse, which patient complaint suggests left-sided heart failure?
|a.||“I have to sleep in my recliner and I have this hacking cough.”|
|b.||“I have no appetite and I have lost 3 lb in the last week.”|
|c.||“I have to urinate every 2 hours, even during the night.”|
|d.||“I go barefoot most of the time because my feet are so hot.”|
- The home health nurse caring for a patient with infective endocarditis overhears the patient making a dental appointment for an extraction next month. Which question is most important for the nurse to ask?
|a.||“Do you have a toothache?”|
|b.||“Have you contacted your physician about your dental appointment?”|
|c.||“Is your dentist board certified?”|
|d.||“Do you think you should wait that long for your tooth extraction?’|
- The home health nurse warns the patient who is taking warfarin (Coumadin) for anticoagulant therapy for thrombophlebitis to stop taking the herbal remedy of ginkgo because ginkgo can:
|a.||cause severe episodes of diarrhea.|
|b.||cause a severe skin eruption if taken with Coumadin.|
|c.||increase the action of the Coumadin.|
|d.||cause the Coumadin to be less effective.|
- What is the difference between primary and secondary hypertension?
|a.||Secondary hypertension is caused by another disorder like renal disease.|
|b.||Secondary hypertension is related to hereditary factors.|
|c.||Secondary hypertension cannot be treated effectively.|
|d.||Secondary hypertension is no real threat to health.|
- The nurse is treating a patient who has had a pacemaker inserted for the correction of atrial fibrillation. Which diagnostic test is no longer available to the patient because of the implanted device?
- Which assessment would lead the nurse to examine the leg closely for evidence of a stasis ulcer?
|a.||Cool dry lower limb|
|b.||Edematous, red scaly skin on medial surface of the leg|
|c.||Lack of hair and shiny appearance of the lower leg|
|d.||Lack of a pedal pulse|
- What is the patient goal of the walking exercise program designed for the rehabilitation of a post-MI patient?
|a.||Walk 2 miles in less than 60 minutes after 12 weeks.|
|b.||Jog mile in less than 30 minutes after 12 weeks.|
|c.||“Fast walk” 1 mile in less than 20 minutes after 12 weeks.|
|d.||Walk 1 mile in 15 minutes without dyspnea after 12 weeks.|
- The postsurgical patient has a painful and swollen right calf that appears to be larger than the calf of the left leg. What is the nurse assessing for when she flexes the patient’s right leg and dorsiflexes the foot?
|a.||Pain, which would be a positive Homans sign|
|b.||Muscular spasm, which would be a sign of hypocalcemia|
|c.||Rigidity, which would be a sign of ankylosis|
|d.||Crepitus, which would be a sign of a joint disorder|
- How should the nurse advise a patient with an international normalized ratio (INR) of 5.8?
|a.||Make arrangements to go to the emergency room immediately|
|b.||Increase fluid intake to 2000 mL/day|
|c.||Stop taking the anticoagulant and notify health care provider|
|d.||Add more leafy green vegetables to patient diet|
- The nurse making a teaching plan for a patient with Buerger disease (thromboangiitis obliterans) will focus on the need for:
|a.||reduction of alcohol intake.|
|b.||avoiding cold remedies.|
|c.||cessation of smoking.|
- Which statement would lead the nurse to offer more instruction about taking warfarin (Coumadin)?
|a.||“I eat a banana every morning with breakfast.”|
|b.||“I try to eat more green leafy vegetables, especially broccoli, spinach, and kale.”|
|c.||“I try to eat a well-balanced, low-fat diet.”|
|d.||“I don’t drink alcohol or caffeine.”|
- The nurse caring for a 92-year-old patient with pneumonia who is receiving IV carefully monitors the flow rate of the IV infusion because rapid infusion can cause:
- The nurse making the schedule for the daily dose of furosemide (Lasix) would schedule the administration for which of the following times?
|a.||Late in the afternoon|
|c.||With any meal|
|d.||In the morning|
- The nurse would assess closely for signs of right-sided heart failure which include (select all that apply):
|b.||increasing abdominal girth.|
|c.||shortness of breath.|
|d.||edema of feet and ankles.|
|e.||distended jugular veins.|
- The nurse would design teaching for a patient with Raynaud disease to include which of the following? (Select all that apply.)
|a.||Warming hands and feet with a heating pad|
|b.||Using mittens in cold weather|
|c.||Practicing stress-reducing techniques|
|d.||Complete smoking cessation|
|e.||Using caution when cleaning the refrigerator or freezer|
- Which information should be taught to patients starting on anticoagulant therapy for a valvular disorder? (Select all that apply.)
|a.||Increase the dose of aspirin for better therapy.|
|b.||Take medication at the same time each day.|
|c.||Report to physician cuts that do not stop bleeding with direct pressure.|
|d.||No restrictions for food or drink.|
|e.||Report for prescribed blood tests (PTT, INR, CBC, blood sugar).|
- What is the transesophageal echocardiogram (TEE) used for? (Select all that apply.)
|a.||Detect thrombi before a cardioversion|
|b.||Check for cardiac arrhythmias|
|c.||Visualize vegetation on the heart valves|
|d.||Measure effectiveness of diuretic therapy|
|e.||Visualize abscesses on the heart valves|
- Which patient teaching would help to prevent venous stasis? (Select all that apply.)
|a.||Dangle legs when sitting|
|b.||Avoid crossing legs at the knee|
|c.||Elevate legs when lying in bed or sitting|
|d.||Massage extremities to help maintain blood flow|
|e.||Wear elastic stockings when ambulating|
- The nurse points out which of the following as modifiable risks for coronary artery disease (CAD)? (Select all that apply.)
- The nurse outlines which of the following as conditions that would disqualify a candidate for a heart transplant? (Select all that apply.)
|c.||Peptic ulcer disease|
|d.||Diabetes type 2|
|f.||Inoperable coronary artery disease|
- When assessing a patient with a possible MI, what should the nurse assess for? (Select all that apply.)
|a.||Pain radiating to left arm and jaw|
|f.||Cardiac rhythm changes|
- Which of the following are signs of digoxin (Lanoxin) toxicity? (Select all that apply.)
|a.||Ringing in the ears|
- The nurse encourages the patient who is recovering from a myocardial infarct (MI) to ask the health care provider to prescribe a cardiac rehabilitation series in order to learn to (select all that apply):
|c.||plan an appropriate diet.|
|d.||select herbal remedies.|
|e.||reduce risk of further problems.|
|f.||understand heart condition.|
- Following an angiogram with the insertion site of the left groin, the nurse will include in the plan of care provisions for (select all that apply):
|a.||checking pedal pulses.|
|b.||ambulating with assistance 2 hours after recovery.|
|c.||checking color and warmth of left leg frequently.|
|d.||sandbagging over insertion site.|
|e.||placing patient in semi-Fowler position.|
- The cardiac marker ___________ rises 3 hours after a myocardial infarct and measures myocardial contractile protein.
- The life support system that uses special techniques, ventilation equipment, and therapies for emergency situations is ________.
- The nurse explains that the heart has the ability to contract in a rhythmic pattern that is called ____________.
- The patient with congestive heart failure who is on a diuretic drug shows a weight loss of 6.6 lb. The nurse is aware that the patient has lost ______ L of fluid.
- The pain that a person with arterial insufficiency feels on exertion, which is relieved by rest, is ______________ _____________.
- The process by which a heart is shocked from a persistent arrhythmia back into sinus rhythm is called a ____________.
- Trace the impulse pattern of conduction in sequence through the heart. (Separate letters by a comma and space as follows: A, B, C, D)
- Atrial wall
- Atrial-ventricular (AV) node
- Purkinje fibers
- Sinoatrial (SA) node
- Bundle branches
- Bundle of His
- Arrange in sequence the path of the blood through the coronary circulation. (Separate letters by a comma and space as follows: A, B, C, D)
- Right atrium
- Pulmonary artery
- Tricuspid valve
- Right ventricle
- Superior and inferior vena cava
- Pulmonary vein
- Left atrium
- Mitral valve
- Left ventricle
Chapter 9: Care of the Patient with a Respiratory Disorder
- What is the purpose of the cilia?
|a.||Warm and moisturize inhaled air|
|b.||Sweep debris toward nasal cavity|
|c.||Stimulate cough reflex|
- What happens when there is a decrease in the oxygen level in the blood?
|a.||Pituitary stimulates the respiratory system to increase respiratory rate|
|b.||The alveoli diffuse more oxygen into the blood|
|c.||Chemoreceptors in the carotid body and aortic body stimulate the respiratory centers to modify respiratory rates|
|d.||The parietal pleura increases the negative pressure|
- A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention?
|a.||Complete care quickly|
|b.||Provide a pad and pencil or magic slate|
|c.||Refrain from conversations with the patient to reduce stress level|
|d.||Offer books or jigsaw puzzles for entertainment|
- A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding?
|a.||Obtain a blood pressure|
|b.||Record the approximate amount of blood lost|
|c.||Inquire about a headache|
|d.||Record the last episode of epistaxis|
- The nurse assessing an 11-year-old who is having an asthma attack expects to hear adventitious sounds of:
- How will the kidneys behave in respiratory acidosis?
|a.||Retain bicarbonate to increase the pH|
|b.||Excrete more urine to reduce potassium|
|c.||Concentrate the urine to conserve circulating fluid in the blood stream|
|d.||Lower the pH by excretion of bicarbonate|
- An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. What is the infected fluid that the physician removes called?
- Which instruction by the nurse is inappropriate for teaching the proper technique for collection of a sputum specimen?
|a.||Bring the sputum up from the lungs|
|b.||Rinse mouth with water before expectorating in specimen cup|
|c.||Collect specimens after meals|
|d.||Send specimen to the lab without delay|
- When assessing the SaO2 with a pulse oximeter, the nurse will place the oximeter on a finger:
|a.||on the same side as the blood pressure cuff.|
|b.||while exercising the arm to stimulate circulation.|
|c.||that is a normal temperature.|
|d.||on the same side as an arterial catheter.|
- A patient, age 69, has emphysema. On assessment, the nurse notes the presence of a “barrel chest.” What does this pathology result from?
|a.||An increase in the lateromedial area from hypertrophy of mucous glands in the bronchi|
|b.||An increased anteroposterior diameter caused by overinflation of the alveoli|
|c.||A decrease in anteroposterior diameter caused by chronic dilation of the bronchi|
|d.||A widening of the sternocostal area secondary to chronic constriction of smooth muscles in the airways leading to bronchospasms|
- A patient, age 22, is admitted with acute asthma. The patient shows a pulse oximetry level of SaO2 of 82%. How should the nurse interpret this?
|a.||Only 82% of the red blood cells are able to use oxygen.|
|b.||There is only 82% of oxygen bound to the hemoglobin compared with the amount available.|
|c.||Eighteen percent of oxygen is not dissolved in the blood.|
|d.||The muscular respiratory effort is only 18% effective.|
- What is the appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis?
|a.||Place the patient in drainage and secretion precautions|
|b.||Place the patient in acid-fast bacillus (AFB) Isolation Precautions|
|c.||Maintain the patient in enteric isolation|
|d.||Place the patient in any Isolation Precautions|
- How should the newly diagnosed patient who has been prescribed isoniazid (INH) for the treatment of active tuberculosis (TB) be advised?
|a.||Report redness and swelling of extremities|
|b.||Accept that the therapy is long term|
|c.||Monitor renal function every several months|
|d.||Rise slowly to avoid dizziness|
- The patient has advanced emphysema and complains of dyspnea and fatigue. What would the most appropriate nursing intervention be for the nursing diagnosis of Activity intolerance related to an imbalance between the oxygen supply and demand?
|a.||Direct patient in vigorous independent ROM.|
|b.||Allow to exercise until respirations are over 20 breaths/min over baseline.|
|c.||Plan care to provide optimum rest.|
|d.||Provide frequent cool showers.|
- A patient is on postoperative day 2 after undergoing a total hip replacement. The patient suddenly complains of chest pain and is coughing up blood-tinged sputum. What should be the nurse’s initial intervention?
|a.||Report signs to the charge nurse.|
|b.||Elevate head of bed and administer oxygen.|
|c.||Prevent patient from excessive coughing.|
|d.||Increase IV flow rate.|
- What is true about activities such as walking for the patient with emphysema?
|a.||Repair dilated alveoli|
|b.||Increase capacity to use oxygen|
|c.||Lessen the oxygen needs|
|d.||Lessen metabolic oxygen needs|
- The patient with long-term emphysema is admitted with a secondary diagnosis of cor pulmonale. What should the nurse anticipate?
|a.||The patient will present with edema of the lower extremities and extended neck veins due to hypertension of the pulmonary circulation.|
|b.||The patient will present with a dry hacking cough and chest pain due to constriction of the pulmonary vein.|
|c.||The patient will present with hypertension and a headache related to pulmonary hypertension.|
|d.||The patient will present with unlabored respiration and cyanosis around the mouth.|
- What is a major advantage of video assisted thoracoscopic surgery (VATS)?
|a.||The surgeon can record entire surgical procedure on a video.|
|b.||The surgeon can remove tumors of the lung through a small keyhole incision.|
|c.||The surgeon can x-ray and excise tumor in the same procedure.|
|d.||The surgeon can avoid the use of a closed chest drainage system after surgery.|
- How would the nurse examining a patient with pleurisy document a low-pitched grating lung sound?
- What is inspiratory capacity?
|a.||The amount of air in the lung after a maximal inhalation|
|b.||The amount of air moved with each normal inhalation and expiration|
|c.||The amount of air that can be inhaled in one breath from the resting expiratory level|
|d.||The amount of air that can be forcefully exhaled after maximum inhalation|
- The older adult patient with long-term emphysema complains of a sharp pleuritic pain after a severe period of coughing. The patient’s heart rate and respiratory rate have increased. Auscultation reveals no breath sounds on the left side. These are signs and symptoms of what condition?
|c.||Early signs of unilateral pneumonia|
|d.||An attack of asthma|
- Which important precaution should the nurse include when instructing an emphysema patient on the use of home oxygen?
|a.||Use oxygen only when extremely short of breath|
|b.||Keep the home oxygen regulator set on 6 L|
|c.||Use home oxygen at night while sleeping|
|d.||Limit to 1 to 2 L oxygen flow|
- The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful?
|a.||In 24 hours, but must take cold liquids for the rest of the day|
|b.||If there is no blood in his sputum|
|c.||In 8 hours after a period of nothing by mouth|
|d.||When the gag reflex returns|
- The nurse caring for a patient who has a closed chest drainage system notes that there is fluctuation (tidaling) in the water seal chamber. What is the most appropriate nursing action based on this assessment?
|a.||Document the tidaling|
|b.||Elevate the head of the bed and notify charge nurse of malfunction of drainage system|
|c.||Add more sterile water to the water seal chamber|
|d.||Turn patient to the affected side|
- How does pursed lip breathing assist patients with asthma during an attack?
|a.||It distracts the patient with breathing technique to reduce anxiety.|
|b.||It gets rid of CO2 faster.|
|c.||It opens bronchioles by backflow air pressure.|
|d.||It increases PACO2..|
- How do leukotriene modifiers reduce the symptoms of asthma?
|a.||By drying up mucus|
|b.||By causing bronchodilation and anti-inflammation effects|
|c.||By suppressing cough|
|d.||By liquefying mucus|
- How should a patient be positioned after a thoracentesis is completed and the dressing applied?
|c.||Side lying on unaffected side|
- What should the nurse do to keep the chest tubes from becoming occluded?
|a.||Irrigate tubes as needed|
|b.||Prevent dependent loops|
|c.||Loop the tube over the bed rail|
|d.||“Milk” the tube frequently|
- Which patient assessment indicates the most severe respiratory distress?
|a.||Nasal flaring, symmetrical chest wall expansion, SaO2 88%|
|b.||Abdominal breathing, SaO2 97%|
|c.||Substernal retraction, SaO2 84%|
|d.||Substernal retraction, SaO2 90%|
- Which preoperative teaching should a nurse include for a person scheduled for a partial laryngectomy? (Select all that apply.)
|a.||Tracheal suction will be frequent|
|b.||The presence of a temporary tracheotomy|
|c.||That isolation will be required for 24 hours|
|d.||The surgery involves removal of a diseased vocal cord|
|e.||Some speech will be retained|
|f.||The sense of smell and taste will be lost|
- Which independent nursing measures are effective in aiding a patient to expectorate? (Select all that apply.)
|a.||Positioning in orthopneic position|
|c.||Assisting to cough|
|e.||Starting IV fluids|
|f.||Starting mucolytic agents|
- Identify the purposes of chest drainage. (Select all that apply.)
|a.||Drains air, blood, and fluid from pleural space|
|b.||Restores positive pressure in chest cavity|
|c.||Restores negative intrapleural pressure|
|d.||Allows lung to collapse and rest|
|e.||Allows route for medication administration|
- What are age-related changes in the older adult that make them at risk for respiratory diseases? (Select all that apply.)
|a.||Moist mucous membranes|
|c.||Decrease in pulmonary blood flow|
|d.||Stasis pooling of secretions|
|e.||Reduced number of cilia|
- The nurse explains to the person with pneumonia in the left lung that being positioned in the “good lung down” offers the advantage of (select all that apply):
|a.||PaO2 rising in the good lung.|
|b.||blood flow to “bad lung” being increased.|
|c.||the dependent lung being better perfused.|
- The _________ are the structures of the lung in which gas exchange occurs.
- The nurse prepares a patient for the procedure of a(n) __________, which will remove the fluid from around the lung to improve respiration and obtain a specimen.
- The nurse explains that the opening between the vocal cords is the __________.
- The nurse recognizes that the _______ reading in an arterial gas report indicates the amount of oxygen dissolved in the plasma.
- The nurse explains that the diagnostic test that can scan the chest and the abdomen in less than 30 seconds is the _____________ _____.
- The nurse traces the path of unoxygenated blood through the respiratory system to the distribution of oxygenated blood to the body. Place the events of reoxygenation in order. (Separate letters by a comma and space as follows: A, B, C, D)
- Pulmonary artery takes blood to capillary system of the alveoli
- Blood enters the left atria via the pulmonary vein
- Blood enter the left ventricle
- Unoxygenated blood enters the right ventricle
- Blood enters the aorta
- CO2 diffused and oxygen infused into the blood in alveoli
- Unoxygenated blood enters the right atrium
- The nurse describes the pathophysiologic process of an asthma attack. Place the events in their proper sequence. (Separate letters by a comma and space as follows: A, B, C, D)
- Inflammatory process in the mast cells of the lungs
- Increase in edema and mucus production in the bronchioles
- Release of histamine
- Narrowing of the airways
- Exposure to allergen
Chapter 10: Care of the Patient with a Urinary Disorder
- What is the hormone from the posterior pituitary gland that influences the amount of water that is eliminated with the urine?
|c.||Antidiuretic hormone (ADH)|
- As the body breaks down protein, nitrogen wastes are broken down into urea, ammonia, and:
- Because the kidneys are located in proximity to the vertebrae and are protected by the ribs, their location in documentation is referred to as:
- A home health patient with end-stage renal disease (ESRD) has a nursing diagnosis of powerlessness related to life-altering disease. Which nursing intervention would be most helpful?
|a.||Ensure restricted protein intake to prevent nitrogenous product accumulation.|
|b.||Include the patient in making the plan of care.|
|c.||Counsel patient about end-of-life provisions.|
|d.||Write out a detailed schedule of physician’s appointments.|
- What portion of the nephron is involved with filtration?
|a.||Glomerulus of the Bowman capsule|
|c.||Proximal convoluted tubule|
|d.||Distal convoluted tubule|
- When the home health patient is started on dialysis, the home health nurse refers the patient to a community support group that assists with the adjustments necessary to living with dialysis. Which group offers this service?
|a.||National Kidney Foundation|
|b.||American Association of Kidney Patients|
|c.||American Red Cross|
- The nurse is aware that as a person ages there is a loss of the __________mechanism of the kidney due to a decrease in blood supply to the kidneys and loss of nephrons.
- A patient who is receiving continuous bladder irrigation following a transurethral resection of the prostate (TURP) complains of “spasm-like” pain over his lower abdomen. What should the initial intervention be by the nurse?
|a.||Inform the nurse in charge|
|b.||Decrease the continuous bladder irrigation flow|
|c.||Administer the prescribed analgesic|
|d.||Check the catheter and drainage system for obstruction|
- A 56-year-old patient with cancer of the bladder is recovering from a cystectomy with an ileal conduit. What is an important aspect in nursing interventions of the patient with an ileal conduit?
|a.||Instructing the patient to void when the urge is felt.|
|b.||Maintaining skin integrity.|
|c.||Limiting oral intake to 1000 mL/day|
|d.||Limiting acid-ash foods.|
- It is 2 days after a 42-year-old male patient’s urinary diversion surgery. He continues to be critical of the hospital and the nursing care, even though the staff has spent time explaining the care to him. What is the most likely explanation for his behavior?
|a.||He is angry about hospital policy.|
|b.||He is feeling neglected by the nursing staff.|
|c.||He is in denial of the effects of the surgery.|
|d.||He is reacting to the loss of self-esteem and altered body image.|
- What should the nurse encourage, barring any other contraindication, when teaching a patient how to decrease the chance of further problems with urolithiasis?
|a.||Increase his fluid intake|
|b.||Increase intake of dairy products|
|c.||Restrict his protein intake|
|d.||Take one baby aspirin daily|
- The nurse notes the amount and color of the urine the patient with urolithiasis has voided. While using Standard Precautions, what should be the nurse’s next action?
|a.||Discard the urine|
|b.||Add the urine to a 24-hour collector|
|c.||Send the urine to the laboratory|
|d.||Strain the urine|
- The nurse assessing a patient who is taking furosemide (Lasix) finds an irregular pulse. This is likely a sign of:
- The patient with nephrosis complains about the need for bed rest. How would the nurse explain the benefit of bed rest?
|a.||The recumbent position may initiate diuresis.|
|b.||It preserves the skin integrity.|
|c.||It lowers the level of albuminuria.|
|d.||It saves stress on joints.|
- What should the nurse instruct the patient to do before obtaining the urine specimen for a urine culture?
|a.||Collect the urine for a 24-hour period|
|b.||Obtain a clean-catch specimen|
|c.||Bring in an early morning specimen|
|d.||Limit fluid intake to concentrate the urine|
- The patient is scheduled for a transurethral resection of the prostate. During preoperative teaching, what should the nurse emphasize about what the patient can expect after the procedure?
|a.||Red drainage from the catheter|
|b.||Limited intake of fluids|
|c.||A sodium-restricted diet|
- A male patient, age 71, has benign prostatic hypertrophy. He is recovering from a trans-urethral prostatic resection. The physician orders removal of the indwelling catheter 2 days after the TURP procedure. What might the patient experience after the catheter is removed?
|a.||Burning on urination|
|b.||Passing of blood clots in the urine|
|c.||Dribbling of urine|
- A patient, age 69, is admitted to the hospital with gross hematuria and history of a 20-lb weight loss during the last 3 months. The physician suspects renal cancer. In obtaining a nursing history from this patient, the nurse recognizes which of the following as a significant risk factor for renal cancer?
|a.||High caffeine intake|
|c.||Use of artificial sweeteners|
- As the nurse and the dietitian review a female patient’s diet plan with her, she shouts that with her diabetes and now the kidney failure, there is just nothing she can eat. She says she might as well eat what she wants, because there is nothing she can do to help herself. Based on the patient’s response, which nursing diagnosis does the nurse identify?
|a.||Noncompliance, risk for, related to feelings of anger|
|b.||Imbalanced nutrition less than body requirements, related to knowledge deficit|
|c.||Anticipatory grieving, related to actual and perceived losses|
|d.||Ineffective coping, related to sense of powerlessness|
- The patient is on postoperative day 1 after having undergone a TURP procedure. He has continuous bladder irrigation (CBI). Actual urine output during continuous bladder irrigation is calculated by:
|a.||measuring and recording all fluid output in the drainage bag.|
|b.||measuring the total output and deducting the total of the irrigating and intravenous solutions.|
|c.||adding the total of the intravenous and irrigating solutions and then deducting the amount of output.|
|d.||measuring total output and deducting the amount of irrigating solution used.|
- A patient has nephrotic syndrome. Which statement made by the patient indicates understanding of the necessary diet modifications?
|a.||“I will need to increase protein and decrease sodium intake.”|
|b.||“I will need to drink more milk to get my calcium.”|
|c.||“Carbohydrate restriction will be difficult.”|
|d.||“Potassium restriction won’t be hard since I don’t like fruit.”|
- What should the patient be encouraged to eat during the active phase of acute renal failure?
|a.||A diet high in sodium|
|b.||A diet high in potassium|
|c.||A diet high in fats|
|d.||A diet high in fluid sources|
- The patient has end-stage renal disease (ESRD) and is admitted to the hospital with a blood urea nitrogen (BUN) level of 48 mg/dL. An excessive elevation of BUN could result from:
- An intravenous pyelogram confirms the presence of a 4-mm renal calculus in the proximal left ureter of a newly admitted patient. Physician orders include meperidine (Demerol) 100 mg IM q4h PRN, strain all urine, and encourage fluids to 4000 mL/day. What should be the nurse’s highest priority when planning care for this patient?
|a.||Pain related to irritation of a stone|
|b.||Anxiety related to unclear outcome of condition|
|c.||Ineffective health maintenance related to lack of knowledge about prevention of stones|
|d.||Risk for injury related to disorientation|
- A patient is receiving chlorothiazide (Diuril), a thiazide diuretic for hypertension. What nursing action is most important for prevention of complications?
|b.||Increase fluid intake|
|c.||Assess for hypokalemia|
|d.||Assess for hypernatremia|
- A patient with cystitis is receiving phenazopyridine (Pyridium) for pain and is voiding a bright red-orange urine. What should the nurse do?
|a.||Report this immediately|
|b.||Explain to the patient that this is normal|
|c.||Increase fluid intake|
|d.||Collect a specimen|
- The patient, age 43, has cancer of the urinary bladder. He has received a cystectomy with an ileal conduit. Which characteristics would be considered normal for his urine?
|b.||Clear amber with mucus shreds|
- A patient, age 78, has been admitted to the hospital with dehydration and electrolyte imbalance. She is confused and incontinent of urine on admission. Which nursing intervention does the nurse include in developing a plan of care?
|a.||Restrict fluids after the evening meal|
|b.||Insert an indwelling catheter|
|c.||Assist the patient to the bathroom every 2 hours|
|d.||Apply absorbent incontinence pads|
- The home health nurse suggests the use of complementary and alternative therapies to prevent and/or treat urinary tract infections (UTIs). Which of the following is an example of such therapies?
- Which action can reduce the risk of skin impairment secondary to urinary incontinence?
|a.||Decreasing fluid intake|
|b.||Catheterization of the elderly patient|
|c.||Limiting the use of medication (diuretics, etc.)|
|d.||Frequent toileting and meticulous skin care|
- Why are pediatric patients, especially girls, susceptible to urinary tract infections?
|a.||Genetically females have a weaker immune system|
|b.||Females have a short and proximal urethra in relation to the vagina|
|c.||Girls are more sexually active than males|
|d.||Girls have a weakened musculature and sphincter tone|
- Which foods should the home health nurse counsel hypokalemic patients to include in their diet?
|a.||Bananas, oranges, cantaloupe|
|b.||Carrots, summer squash, green beans|
|c.||Apples, pineapple, watermelon|
|d.||Winter squash, cauliflower, lettuce|
- To help a patient control incontinence, what should the nurse recommend the patient avoid?
- What should the nurse counsel the young man with chronic prostatitis to avoid?
|a.||Cessation of intercourse|
|d.||Continuing antibiotics when symptoms abate|
- The nurse reassures the patient recovering from acute glomerulonephritis that after all other signs and symptoms of the disease subside, it is normal to have some residual (select all that apply):
- Why are urinary tract infections (UTI) common in older adults? (Select all that apply.)
|a.||Older adults have weakened musculature in the bladder and urethra.|
|b.||Older adults have urinary stasis.|
|c.||Older adults have increased bladder capacity.|
|d.||Older adults have diminished neurologic sensation.|
|e.||The effects of medications such as diuretics that many older adults take.|
- Which of the following are signs of fluid overload in the patient with nephrosis? (Select all that apply.)
|a.||Increase in pulse rate|
|b.||Increase in daily weight|
|c.||Clear lung sounds|
- The nurse is reviewing the urinalysis report on an assigned patient. The nurse recognizes which findings to be normal? (Select all that apply.)
|d.||Red blood cells, 15 to 20|
|e.||White blood cells|
- Exercises to increase muscle tone of the pelvic floor are known as ____________ exercises.
- _____________ is a term for severe generalized edema.
- Acute glomerulonephritis is commonly a result of a preexisting infection of _____________.
- The prostatectomy technique, which involves an incision through the abdomen and the bladder, is a ____________prostatectomy.
- _________ is a prostatic pain without evidence of infection or inflammation.
- In the nephrotic syndrome, the glomeruli are damaged by inflammation and allow small _______ to pass through into the urine.
- Put the sequence of blood flow in order of flow through the nephron. (Separate letters by a comma and space as follows: A, B, C, D)
- Reabsorption in loop of Henle
- Efferent arteriole
- Filtration in the glomerulus
- Reabsorption in proximal convoluted tubule
- Afferent arteriole
- Secretion in the distal convoluted tubule
Chapter 11: Care of the Patient with an Endocrine Disorder
- The nurse explains that the negative feedback system controls hormone release by communication between:
|a.||the pituitary and the target organ.|
|b.||the thymus and the blood stream.|
|c.||lymphatic system and the target organ.|
|d.||central nervous system and the blood stream.|
- Which diagnostic test for diabetes mellitus provides a measure of glucose levels for the previous 8 to 12 weeks?
|a.||Fasting blood sugar (FBS)|
|b.||Oral glucose tolerance test (OGT)|
|c.||Glycosylated hemoglobin (HbA1c)|
|d.||Postprandial glucose test (PPBG)|
- Which test will furnish immediate feedback for a newly diagnosed diabetic who is not yet under control?
|a.||Fasting blood sugar (FBS)|
|b.||Glycosylated hemoglobin (HgbA1c)|
|c.||Oral glucose tolerance test (OGTT)|
- To which diet should a patient with Cushing syndrome adhere?
- The patient is a 20-year-old college student who has type 1 diabetes and normally walks each evening as part of an exercise regimen. The patient plans to enroll in a swimming class. Which adjustment should be made based on this information?
|a.||Time the morning insulin injection so that the peak action will occur during swimming class.|
|b.||Delete normal walks on swimming class days.|
|c.||Delay the meal before the swimming class until the session is over.|
|d.||Monitor glucose level before, during, and after swimming to determine the need for alterations in food or insulin.|
- What is a long-term complication of diabetes mellitus?
- A patient has returned to his room after a thyroidectomy with signs of thyroid crisis. During thyroid crisis, exaggerated hyperthyroid manifestations may lead to the development of the potentially lethal complication of:
|a.||severe nausea and vomiting.|
|c.||delirium with restlessness.|
|d.||congestive heart failure.|
- In diabetes insipidus, a deficiency of which hormone causes clinical manifestations?
|a.||antidiuretic hormone (ADH)|
|b.||follicle-stimulating hormone (FSH)|
|c.||thyroid-stimulating hormone (TSH)|
|d.||adrenocorticotropic hormone (ACTH)|
- What is an appropriate nursing diagnosis for a patient who has recently been diagnosed with acromegaly?
|c.||Risk for trauma|
|d.||Chronic low self-esteem|
- The purpose of the use of radioactive iodine in the treatment of hyperthyroidism is to:
|a.||stimulate the thyroid gland.|
|b.||depress the pituitary.|
|c.||destroy some of the thyroid tissue.|
|d.||alter the stimulus from the pituitary.|
- Which precaution(s) should the nurse take when caring for a patient who is being treated with radioactive iodine 131 (RAIU)?
|a.||Initiate radioactive safety precautions|
|b.||Avoid assigning any young woman to the patient|
|c.||Wait three days after dose before assigning a pregnant nurse to care for this patient|
|d.||Advise visitors to sit at least 10 feet away from the patient|
- Why would a patient with hyperthyroidism be prescribed the drug methimazole (Tapa-zole)?
|a.||To limit the effect of the pituitary on the thyroid|
|b.||To destroy part of the hyperactive thyroid tissue|
|c.||To stimulate the pineal gland|
|d.||To block the production of thyroid hormones|
- What is the postoperative position for a person who has had a thyroidectomy?
- What extra equipment should the nurse provide at the bedside of a new postoperative thyroidectomy patient?
|a.||Large bandage scissors|
|d.||Water-sealed drainage system|
- As the nurse is shaving a patient who is 2 days postoperative from a thyroidectomy, the patient has a spasm of the facial muscles. What should the nurse recognize this as?
- The human insulin whose onset of action occurs within ____ minutes is lispro (Humalog).
- What should the nurse caution a type I diabetic about excessive exercise?
|a.||It can increase the need for insulin and may result in hyperglycemia.|
|b.||It can decrease the need for insulin and may result in hypoglycemia.|
|c.||It can increase muscle bulk and may result in malabsorption of insulin.|
|d.||It can decrease metabolic demand and may result in metabolic acidosis.|
- What do the Chvostek sign and the Trousseau sign indicate?
|a.||Low levels of serum calcium|
|b.||High levels of blood sugar|
|c.||Low levels of serum sodium|
|d.||High levels of serum aldosterone|
- A patient has undergone tests that indicate a deficiency of the parathyroid hormone secretion. She should be informed of which potential complication?
- The nurse caring for a 75-year-old man who has developed diabetes insipidus following a head injury will include in the plan of care provisions for:
|a.||limiting fluids to 1500 mL a day.|
|b.||encouraging physical exercise.|
|c.||protecting patient from injury.|
|d.||discouraging daytime naps.|
- The physician orders an 1800-calorie diabetic diet and 40 units of (Humulin N) insulin U-100 subcutaneously daily for a patient with diabetes mellitus. Why would a mid-afternoon snack of milk and crackers be given?
|a.||To improve nutrition|
|b.||To improve carbohydrate metabolism|
|c.||To prevent an insulin reaction|
|d.||To prevent diabetic coma|
- The nurse teaching a patient with type 1 diabetes mellitus (IDDM) about early signs of
insulin reaction would include information about:
|a.||abdominal pain and nausea.|
|b.||dyspnea and pallor.|
|c.||flushing of the skin and headache.|
|d.||hunger and a trembling sensation.|
- The nurse discovers the type 1 diabetic (IDDM) patient drowsy and tremulous, the skin is cool and moist, and the respirations are 32 and shallow. These are signs of:
|a.||hypoglycemic reaction; give 6 oz of orange juice.|
|b.||hyperglycemic reaction; give ordered regular insulin.|
|c.||hyperglycemic hyperosmolar nonketotic reaction; squeeze glucagon gel in buccal cavity.|
|d.||hypoglycemic reaction; give ordered insulin.|
- A patient has come to the clinic because of enlarged hands and feet, amenorrhea, and increased hair growth. These symptoms most likely indicate problems with the:
- What instructions should a nurse give to a diabetic patient to prevent injury to the feet?
|a.||Soak feet in warm water every day.|
|b.||Avoid going barefoot and always wear shoes with soles.|
|c.||Use of commercial keratolytic agents to remove corns and calluses are preferred to cutting off corns and calluses.|
|d.||Use a heating pad to warm feet when they feel cool to the touch.|
- The physician prescribes glyburide (Micronase, DiaBeta, Glynase) for a patient, age 57, when diet and exercise have not been able to control type 2 diabetes. What should the nurse include in the teaching plan about this medication?
|a.||It is a substitute for insulin and acts by directly stimulating glucose uptake into the cell.|
|b.||It does not cause the hypoglycemic reactions that may occur with insulin use.|
|c.||It is thought to stimulate insulin production and increase sensitivity to insulin at receptor sites.|
|d.||It lowers blood sugar by inhibiting glucagon release from the liver, preventing gluconeogenesis.|
- A 27-year-old patient with hypothyroidism is referred to the dietitian for dietary consultation. What should nutritional interventions include?
|a.||Frequent small meals high in carbohydrates|
- What instructions should be included in the discharge instructions for a 47-year-old patient with hypothyroidism?
|a.||Taking medication whenever symptoms cause discomfort|
|b.||Decreasing fluid and fiber intake|
|c.||Consuming foods rich in iron|
|d.||Seeing the physician regularly for follow-up care|
- How should the nurse administer insulin to prevent lipohypertrophy?
|a.||At room temperature|
|b.||At body temperature|
|c.||Straight from the refrigerator|
|d.||After rolling bottle between hands to warm|
- A patient with a history of Graves disease is admitted to the unit with shortness of breath. The nurse notes the patient’s vital signs: T 103° F, P 160, R 24, BP 160/80. The nurse also notes distended neck veins. What does the patient most likely have?
- What is the master gland of the endocrine system?
- What information should be obtained from the patient before an iodine-131 test?
|a.||Presence of metal in the body|
|b.||Allergy to sulfa drugs|
|c.||Status of possible pregnancy|
|d.||Use of prescription drugs for hypertension|
- The patient being treated for hypothyroidism should be instructed to eat well-balanced meals including intake of iodine. Which of the following foods contains iodine?
- The nurse is caring for a patient who is receiving calcium gluconate for treatment of hypoparathyroid tetany. Which assessment would indicate an adverse reaction to the drug?
|a.||Increase in heart rate|
|b.||Flushing of face and neck|
|c.||Drop in blood pressure|
- The nurse cautions the patient who is being instructed on self-medication with insulin to be aware that there are 25-, 30-, 50-, and 100-unit syringes. How is the 100-unit syringe marked?
- Which of the following are signs and symptoms of hypoglycemia? (Select all that apply.)
- What are the three major life-threatening complications postoperatively of a thyroidectomy? (Select all that apply.)
|e.||Thyroid crisis (storm)|
- The adrenal cortex secretes glucocorticoids. The most important is cortisol. What is it involved in? (Select all that apply.)
|b.||Releasing androgens and estrogens|
|c.||Providing extra reserve energy during stress|
|d.||Decreasing the level of potassium in the blood stream|
|e.||Increasing retention of sodium in the blood stream|
- What should the nurse include in provisions for the postoperative care of the patient who had a thyroidectomy? (Select all that apply.)
|a.||Assessing ability to speak by asking him or her to recite name and address every hour|
|b.||Maintaining anatomic position of the head when moving a patient|
|c.||Assisting a patient to hyperextend the head to assess for muscle damage|
|d.||Doing voice check every 2 hours|
|e.||Turning, coughing every hour|
|f.||Checking for bleeding at the sides and the back of the head|
- The nurse would instruct a patient with hyperthyroidism (Graves disease) to select which of the following nutritious foods because of the increased metabolism related to the disease. (Select all that apply.)
|a.||Coffee with cream|
|d.||Leafy green vegetables|
|e.||Supplemental vitamin D|
- The nurse would instruct a patient who is hypocalcemic from hypoparathyroidism about a diet that should include (select all that apply):
|a.||High phosphorus foods|
|b.||Canned fish with the bones|
|f.||Vitamin D supplements|
- The nurse is administering long-acting insulin once a day, which provides insulin coverage for 24 hours. This insulin is _________________.
- Another term for hyperglycemic reaction is ____________ ______________.
- Only ________insulin can be administered intravenously.
- A condition with a deficiency in growth hormone is called ________________.
- ________________is the term that describes a condition of normal thyroid function.
- When the nurse inflates the sphygmomanometer cuff exceeding the systolic blood pressure and observes a carpal spasm, this is a(n) __________ ____________.
- Arrange the steps of the negative feedback system in the control of blood glucose in chronologic order. (Separate letters by a comma and space as follows: A, B, C, D):
- Elevation of blood glucose
- Decrease in blood glucose
- Beta cells repressed
- Beta cells of pancreas stimulated to excrete insulin
- Intake of nutrients
- Arrange the steps of drawing up a short-acting and a long-acting insulin in the same syringe. (Separate letters by a comma and space as follows: A, B, C, D)
- Draw up amount of shorter-acting insulin
- Check insulin dose with a second licensed nurse
- Inject the desired amount of air into the long-acting insulin
- Clean rubber stopper of both vials with alcohol
- Draw up desired amount of longer-acting insulin
- Inject the desired amount of air into the short-acting insulin
Chapter 12: Care of the Patient with a Reproductive Disorder
- Which condition would prevent the use of a vaginal hysterectomy?
|a.||A woman with more than four pregnancies|
|b.||Large uterine fibroids|
|c.||Menorrhagia for over 6 months|
|d.||Women over the age of 50|
- On the second postoperative day, a patient who has had an abdominal hysterectomy complains of gas and abdominal distention. Which intervention would be most appropriate to stimulate a bowel movement?
|a.||Offering carbonated beverages|
|b.||Encouraging ambulation at least four times per day|
|c.||Administering a 1000-mL soapsuds enema|
|d.||Applying an abdominal binder|
- The young husband of a patient who has been scheduled for a hysterectomy because of the discovery of ovarian cancer in both ovaries says to the nurse, “Please go talk to my wife. She is real upset and says she won’t be a ‘woman’ anymore.” What is the nurse’s most therapeutic response?
|a.||“Don’t be concerned. All young women get upset before this kind of surgery.”|
|b.||“Certainly, I will be glad to tell her about hormone replacement.”|
|c.||“She will get over this feeling soon.”|
|d.||“No matter what I may say to her, it is you that needs to listen to her concerns and assure her.”|
- A patient, age 41, has had a total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometriosis. She asks the nurse if she will have “hot flashes.” What knowledge will guide the nurse’s response?
|a.||Only the uterus was removed, and the ovaries are still producing estrogen and she will not have hot flashes.|
|b.||The patient is too young to have hot flashes associated with menopause.|
|c.||The uterus, ovaries, and fallopian tubes were removed, and she will have surgically induced menopause and may have hot flashes.|
|d.||The uterus and fallopian tubes were removed, and she will not experience “hot flashes.”|
- On the fourth postoperative day after a modified radical mastectomy, the nurse finds the patient with her back to the nurse. She is crying and tells the nurse she feels ugly and is worried that her husband will not be in love with her anymore. The nurse bases subsequent nursing interventions on what diagnosis?
|a.||Disturbed body image related to removal of her breast|
|b.||Deficient knowledge related to inadequate education|
|c.||Impaired social interaction related to depression|
|d.||Fear related to the cancer diagnosis and surgical intervention|
- Why would the nurse encourage the patient who is recovering from a modified radical mastectomy to exercise the affected arm?
|a.||To reduce pain|
|b.||To stimulate appetite|
|c.||To reduce lymphedema|
|d.||To increase muscle tension|
- A 20-year-old patient presents in the emergency room with a temperature of 103° F, blood pressure of 92/58, headache, and desquamation of both palms. What should the nurse make sure to ask about during the interview?
|a.||Any recent traveling outside the country|
|b.||Immunization against influenza|
|c.||Method of birth control|
|d.||Use of tampons|
- At what age should a male be taught testicular self-examination (TSE)?
- Which statement made by a patient who has been taught the technique of testicular self-examination indicates the need for further teaching?
|a.||“The testes feel smooth and egg-shaped.”|
|b.||“The best time to perform TSE is after a shower.”|
|c.||“I will examine my scrotum after every ejaculation.”|
|d.||“The epididymis feels like a soft tube.”|
- Which patient is most at risk for the infection of epididymitis?
|a.||17-year-old athlete who trains for several hours a day|
|b.||22-year-old who has been exposed to mumps|
|c.||45-year-old who was circumcised at the age of 10|
|d.||50-year-old who has smoked for 30 years|
- A patient, age 26, has had a tubal insufflation (Rubin test) to ascertain whether her fallopian tubes are patent. She complains of pain in her right shoulder. Which response is most appropriate?
|a.||“Don’t worry, that is a normal reaction.”|
|b.||“I’ll report the findings immediately to the head nurse.”|
|c.||“That is a symptom that resulted from your position on the operating table.”|
|d.||“That is from the carbon dioxide passing from the fallopian tubes into your abdomen.”|
- The nurse provides discharge teaching for a patient regarding her activity level as she recovers from her modified radical mastectomy. Which statement by her indicates to the nurse that the teaching has been successful?
|a.||“I should sleep on the side opposite my mastectomy.”|
|b.||“I should keep my right arm supported in a sling when I am up and around until my incision is healed.”|
|c.||“I can do whatever exercises and activities I want as long as I don’t elevate my right hand above my head.”|
|d.||“I should take aspirin before moving or exercising my arm to prevent pain during the exercises.”|
- A female patient, age 48, is undergoing a routine physical examination for the first time in 5 years. Which procedure would be included in this examination?
- What is the recommended age range for a baseline mammogram?
|a.||25 and 30 years|
|b.||31 and 34 years|
|c.||35 and 39 years|
|d.||40 and 45 years|
- What does the diagnosis of secondary infertility refer to?
|a.||Has never conceived|
|b.||Is infertile because of repeated infection|
|c.||Has conceived but is now unable to do so|
|d.||Is over the age of 38|
- What instruction should a nurse give a patient with congenital herpes who does not have lesions at the present?
|a.||“Continued use of acyclovir (Zovirax) will prevent reinfection by the virus.”|
|b.||“Condoms should be used during all sexual activity to prevent transmission of the virus, even when lesions are not present.”|
|c.||“Acyclovir ointment should be applied to the lesions to increase comfort and speed healing.”|
|d.||“Recurrent genital herpes is promoted by any sexual stimulation.”|
- The 10-year-old clinic patient reports that she is free of gonorrhea and can now engage in sexual activity. Which response is most appropriate?
|a.||“If you have been free of symptoms for 2 weeks you are cured.”|
|b.||“You should get a rapid plasma reagin (RPR) just to make sure.”|
|c.||“No case is considered cured until you have had three consecutive negative cervical smears.”|
|d.||“To confirm your cure, you should get a Venereal Disease Research Lab (VDRL).”|
- A Gram stain smear of the patient’s discharge reveals the presence of N. gonorrhoeae. He tells the nurse that he had sexual contact with a new girlfriend but does not think he was exposed to gonorrhea because she did not appear to have any disease. Which information should the nurse include in response to his comment?
|a.||“Women do not develop gonorrhea infections but can serve as carriers to spread the disease to males.”|
|b.||“When gonorrhea infections occur in women, the disease affects only the ovaries and not the other genital organs.”|
|c.||“Many women are not aware that they have gonorrhea because they often do not have symptoms of infection.”|
|d.||“Women develop subclinical cases of gonorrhea that do not cause tissue damage or symptoms.”|
- The patient who had a colporrhaphy for the repair of a cystocele and rectocele asks that the catheter be removed as it is bothersome to her. How should the nurse explain the reason for the catheter?
|a.||It replaces uncomfortable gauze packing|
|b.||It will prevent adhesions and will be in place for about 2 weeks|
|c.||It allows for quick urine sample collection|
|d.||It keeps the bladder empty, and prevents stress on the sutures|
- Why is a mammogram the most useful method of diagnosing breast cancer?
|a.||It is the most reliable method of detecting breast cancer before it becomes palpable.|
|b.||It is inexpensive and covered by most medical insurance plans.|
|c.||It involves no radiation and takes only a few minutes.|
|d.||It involves no pain or discomfort and is readily available.|
- The patient, age 52, is recovering from a modified radical mastectomy. Why is postoperative elevation of the patient’s arm important after this procedure?
|a.||To prevent vascular and lymph stasis, thus lymphedema|
|b.||To prevent drainage accumulation at the incisional site|
|c.||To prevent wound infection and dehiscence|
|d.||To prevent pleural effusion and respiratory distress|
- A patient, age 46, is recovering from an abdominal hysterectomy. Postoperative nursing assessment findings include a urinary output of 100 mL in 4 hours. What should the nurse do?
|b.||Report urinary retention to the charge nurse|
|c.||“Milk” the urinary catheter|
|d.||Turn the patient onto her right side|
- When should postmenopausal women be instructed to perform breast self-examination (BSE)?
|a.||On the same date of their choice each month|
|b.||Every 3 months|
|c.||Every day, because they are at high risk for breast cancer|
|d.||Whenever they begin to take estrogen supplements|
- Which statement indicates that the patient who has had an abdominal hysterectomy needs further home teaching?
|a.||“I understand I can lift as much as 20 lb.”|
|b.||“I’m leaving today to stay with my daughter, who lives 20 miles away. My husband plans to drive the family car.”|
|c.||“The doctor said I can’t have sexual intercourse for 4 to 6 weeks.”|
|d.||“I’m going to miss wearing my girdle or knee-high hose.”|
- The patient with a swollen scrotum is amazed that diagnosis of the condition of hydrocele is such a simple thing as:
|a.||placing the scrotum on a warm pad.|
|b.||shining light through scrotum.|
|c.||squatting and letting the scrotum hang dependently.|
|d.||packing the scrotum in ice.|
- A patient, age 36, is scheduled for a unilateral orchiectomy for treatment of testicular cancer. He is withdrawn and does not initiate interaction with the nurse. What is the most appropriate nursing action at this time?
|a.||Carefully explain the postoperative activity restrictions.|
|b.||Show him a diagram of what the orchiectomy will accomplish.|
|c.||Assure him that he will have adequate future sexual functioning.|
|d.||Assess his concerns related to his diagnosis and treatment.|
- The 69-year-old patient laughs at the nurse when the nurse suggests that she should have a Pap smear and says, “I had my uterus removed except for the cervix 30 years ago and I am almost 70. Why in the world would I want to get a Pap smear at my age?” What is the nurse’s most informative reply?
|a.||“All persons who have a cervix remaining should be screened up to the age of 75.”|
|b.||“Well, you have one more year to go to get a Pap smear.”|
|c.||“My goodness, you look so young I thought you were still in the age bracket for regular Pap screens.”|
|d.||“You are right. If you had no trouble so far, there is no need to do the smear.”|
- A male patient, age 23, seeks care at the health clinic because he has developed a profuse, purulent urethral discharge, and urination is painful. During assessment of the patient, it is most important that the nurse gather information related to his history of:
|a.||recent urinary infections.|
|b.||episodes of prostatitis.|
|c.||contagious diseases like mumps.|
|d.||present and past sexual partners, and notify them to get treatment.|
- A 25-year-old woman comes to the clinic with a yellowish-green malodorous vaginal discharge. She says it makes her itch and makes it hard to urinate. After a microscopic examination that confirms trichomoniasis, the patient is placed on metronidazole (Flagyl) for 7 days. How should the nurse advise the patient?
|a.||Avoid alcohol while on Flagyl|
|b.||Be aware that her urine may turn blue and will stain clothing|
|c.||Wear snug underwear during treatment|
|d.||Be aware that she need not notify her sexual partners as trichomoniasis is not contagious|
- The young woman comes to the free clinic for the complaint of stomach cramps. During the examination, the nurse recommends that she be tested for chlamydia. The woman says “I don’t need any test…I don’t have any symptoms for a sexual infection…I just came for my stomach.” Which response is most informative?
|a.||“Well, if you get more symptoms come back for testing.”|
|b.||“The doctor may have to order medicine for syphilis and chlamydia. You probably have that too. You need to be tested today!”|
|c.||“Testing is not mandatory…I probably wouldn’t bother either since you have no symptoms.”|
|d.||“That stomachache may be part of a chlamydia infection. Many women do not have a discharge, but are carriers.”|
- What factor influences older women’s reluctance to seek medical care for problems of the reproductive system?
|a.||Embarrassment and cultural factors|
|d.||Lack of free time|
- Although menopause is a normal part of aging, why do many women enter menopause at an earlier age?
|a.||Having become sexually active at an early age|
|b.||Living at high altitudes|
|c.||Excessive use of alcohol|
- Why do false-negative results in mammography occur in specific age groups?
|a.||Older women have greater density of breast tissue.|
|b.||Older women have less density of breast tissue.|
|c.||Younger women have greater density of breast tissue.|
|d.||Younger women have less density of breast tissue.|
- Vaginal fistulas are caused by an ulcerating process resulting from (select all that apply):
|d.||Multiple sexual partners|
|e.||Weakening of tissue from pregnancies|
- Select the interventions that should be performed with caution, in the affected arm, on patients who have undergone a modified radical mastectomy. (Select all that apply.)
|b.||Taking of blood pressure or samples|
|c.||Insertion of IV line|
|d.||Physical therapy on uninvolved arm|
|e.||Wear watch and jewelry on involved arm|
|f.||Carry purse on involved arm or shoulder|
- What are some advantages of a vaginal hysterectomy over the abdominal hysterectomy? (Select all that apply.)
|a.||Less postoperative discomfort|
|b.||Reduced hospital stay|
|d.||Better visualization of the intrapelvic area|
- The nurse instructs a group of women who attend the health clinic that persons who are particularly at risk for cervical cancer are persons who (select all that apply):
|c.||Have been sexually active since their teens|
|d.||Have multiple sexual partners|
|e.||Had chickenpox as a child|
|f.||Have a history of sexually transmitted diseases (STD)|
- Which of the following are true of the Gardasil vaccine? (Select all that apply.)
|a.||It requires two more immunizations at 6 months after the first dose|
|b.||It reduces incidence of cervical cancer|
|c.||It reduces the incidence of human papilloma virus (HPV)|
|d.||It can be given only to females|
|e.||It should be given before a person becomes sexually active|
|f.||It is safe for people as young as 8 years of age|
- A ___________ is performed to evaluate living tissue to establish or confirm a diagnosis or to follow the course of a disease.
- The nurse is assisting the physician in removing a small sample of tissue from the patient’s cervix to have it evaluated. This procedure is called a cervical _______________.
- _____________ are the most benign tumors of the uterus and arise from the uterine muscle tissue.
- ________are produced in the seminiferous tubules and stored in the epididymis.
- An alternative remedy, ____________ , is used by men for the treatment of impotence.
- When the veins in the scrotum become dilated, and the scrotum becomes enlarged and dilated, the condition is called a __________.
- Arrange the process of the menstrual cycle in order of their function to produce menses. (Separate letters by a comma and space as follows: A, B, C, D)
- Egg matures in the graafian follicle
- Corpus luteum is formed from old follicle
- Estrogen from the maturing follicle causes vascularization of the uterine lining
- Anterior pituitary releases luteinizing hormone (LH), releasing the ovum
- Anterior pituitary releases follicle-stimulating hormone (FSH)
- Corpus luteum releases estrogen and progesterone
- Corpus luteum disintegrates causing a decrease in progesterone
- Lining of uterus is shed as menses
- The nurse gives discharge instructions to a person who has had a modified radical mastectomy of the right side to perform the “elbow pull-in.” Place the steps of the exercise in appropriate order. (Separate letters by a comma and space as follows: A, B, C, D)
- Pull elbows forward until they touch
- Lower and straighten the arms
- Extend arms sideways to shoulder level
- Bring elbows back and extend arms
- Clasp hands behind neck
Chapter 13: Care of the Patient with a Sensory Disorder
- The nurse is aware that the patient has 20/40 vision. This means that the patient can see at 20 feet what the normal eye can see at _______ feet.
- The patient tells the nurse that he is legally blind. How would this information impact the nurse’s plan of care for this patient?
|a.||The patient would be considered totally blind.|
|b.||This patient probably has some light perception, but no usable vision.|
|c.||This patient has some usable vision, which enables function at an acceptable level.|
|d.||The nurse would need to determine how this patient’s visual impairment affects normal functioning.|
- One of the housekeepers splashes a chemical in the eyes. What should be the first priority?
|a.||Transport to a physician immediately|
|b.||Cover the eyes with a sterile gauze|
|c.||Irrigate with H2O for 5 minutes|
|d.||Irrigate with normal saline solution for 20 minutes|
- What does a tympanoplasty correct?
|a.||Conductive hearing loss|
|b.||Sensorineural hearing loss|
|c.||Congenital hearing loss|
|d.||Functional hearing loss|
- The 62-year-old home health patient who is recovering from eye surgery complains of a feeling of “grittiness” in the eye and is having blurred vision. The eyes are reddened and have stringy mucus. What do these complaints indicate?
- Four hours after a stapedectomy the patient complains that hearing has not improved at all. What knowledge would the nurse use to shape a response?
|a.||A large percentage of stapedectomies are not successful|
|b.||It will take at least 10 days for the graft to heal|
|c.||Hearing will not return until edema subsides|
|d.||Hearing will improve after irrigation of the ear|
- What is a common mistake that hinders communication when communicating with the hearing impaired?
|b.||Facing the patient when speaking|
|c.||Speaking in conversational tones|
|d.||Speaking into the ear with the hearing aid|
- What is the process when the lens of the eye changes its curvature to focus on the retina?
- When the newly blind male home health patient asks the nurse how he might get assistance, who might the nurse suggest he contact?
|a.||American Red Cross|
|b.||American Foundation for the Blind for a list of agencies|
|c.||Local hospital social worker|
|d.||The public health department|
- The nurse clarifies that the difference between a photorefractive keratectomy (PRK) and a laser in-situ keratomileusis (LASIK) is that a LASIK:
|a.||reshapes the central cornea.|
|b.||makes partial-thickness radial incisions in the cornea.|
|c.||removes some internal layers of the cornea.|
|d.||implants intracorneal rings.|
- What does the cataract treatment of phacoemulsification involve?
|a.||“Drying” the cataract with hypertonic saline|
|b.||Removing the lens through the anterior capsule|
|c.||The insertion of a new lens|
|d.||Breaking the cataract with ultrasound|
- Which complaint made by a 64-year-old patient during a health interview would alert the nurse to the possibility of cataracts?
|a.||Pain in the eyes|
|b.||Difficulty driving at night|
|c.||Loss of peripheral vision|
- What should a patient who has had a cataract repair avoid?
|a.||The use of eye patches|
|b.||The use of sunglasses|
|c.||The lifting of heavy objects|
|d.||Reading for long periods of time|
- What does diabetes retinopathy result from?
|a.||Capillaries in retina hemorrhage|
|b.||Long-term overdosing of insulin|
- When the patient in the emergency room complains of seeing flashing lights and a curtain down over his right eye, the nurse recognizes this as a symptom of which condition?
|c.||Early sign of cataract|
- The nurse will assess for _____________ when the older adult home health patient complains that the entire right side of his head hurts and he cannot chew without pain.
- The nurse takes into consideration that the Weber test indicated a conductive hearing loss in a patient because the patient reported hearing the tone:
|a.||equally in both ears.|
|b.||as a shrill noise.|
|c.||louder in his affected ear.|
- What should the nurse remind the hearing aid wearer to do when the nurse hears a whistling hearing aid?
|a.||Reinsert the ear mold|
|b.||Change the battery|
|c.||Recharge the hearing aid|
|d.||Wash the ear mold with warm water|
- What should the nurse advise the 20-year-old to do who has been put on cefaclor (Ceclor) for a resistant otitis media?
|a.||Store suspension at room temperature|
|b.||Discontinue drug when symptoms abate|
|c.||Avoid alcoholic beverages|
|d.||Take with meals only|
- How should the nurse advise a patient who has severe vertigo from labyrinthitis?
|a.||Lean against a wall and not head forward until vertigo lessens.|
|b.||Bend at the waist and take several deep breaths.|
|c.||Drink an iced drink slowly.|
|d.||Lie immobile and hold the head in one position until the vertigo lessens.|
- What do miotic eyedrops do for a patient with glaucoma?
|a.||Dilate the pupil and sharpen vision|
|b.||Lubricate and moisten the dry eye|
|c.||Irrigate the surface of the eye|
|d.||Constrict the pupil and open the canal of Schlemm|
- What should the nurse include in the plan of care following a tympanoplasty?
|a.||Elevating head of bed with operative side facing upward|
|b.||Enforcing bed rest for 72 hours|
|c.||Frequent turning, coughing, and deep breathing|
|d.||Continuous irrigation of the ear canal with antibiotic solutions|
- When the patient stares at the black dot on an Amsler grid, what should the nurse ask him to report?
|a.||Any color visible on the grid|
|b.||Fading of the edges of the grid|
|c.||Any distortion of the grid|
|d.||Movement of the black dot|
- A patient who had an enucleation of the right eye has been admitted PACU. What should the nurse include in the plan of care?
|a.||Turn, cough, and deep breathe every 3 hours|
|b.||Apply a pressure dressing over the right eye socket|
|c.||Document dressing assessment every 2 hours|
|d.||Turn on the affected side|
- What must a patient do following a left vitrectomy?
|a.||Remain flat in bed for 48 hours|
|b.||Position self in a face-down position for 4 to 5 days|
|c.||Assume a side-lying position with the left side down for 3 days|
|d.||Keep head upright and cushioned with pillows for 24 hours|
- How would the nurse explain the purpose of photocoagulation to a diabetic patient with diabetic retinopathy?
|a.||The procedure will destroy the retina, which is not getting enough blood supply.|
|b.||The procedure will reduce edema in the macula of the eye.|
|c.||The procedure will vaporize fatty deposits that appear in the retina.|
|d.||The procedure will destroy new blood vessels, seal leaking vessels, and help prevent retinal edema.|
- What is the first indication of macular degeneration?
|a.||The loss of peripheral vision|
|b.||The loss of central vision|
|c.||The loss of color discrimination|
- Which is a sign of acute angle closure glaucoma (AACG)?
|a.||Large fixed pupil|
|c.||Bluish color in sclera|
- Why is otitis media found more frequently in children 6 to 36 months?
|a.||Eustachian tubes in children are shorter and straighter.|
|b.||Infection descends via the eustachian tube to the throat.|
|c.||Children’s eustachian tubes are more vertical and longer.|
|d.||Otitis media is seen equally in both children and adults.|
- Why would the nurse encourage a group of teenagers to protect their eyes with dark sunglasses while using a UV lamp?
|a.||The lamp can cause cataracts.|
|b.||The lamp can cause presbycusis.|
|c.||The lamp can cause keratitis.|
|d.||The lamp can cause ectropion.|
- The nurse counsels the 16-year-old boy that playing his music at high volume can result in impairment in hearing related to:
|a.||damaged tympanic membrane.|
|b.||protective buildup of cerumen.|
|c.||damage of the fine hair cells in the organ of Corti.|
|d.||rupture of the oval window.|
- Select all the conditions that may cause conductive hearing loss. (Select all that apply.)
|a.||Buildup of cerumen|
|c.||Otosclerosis of external auditory canal|
|e.||Exposure to ototoxic drugs|
|f.||Otitis media with effusion|
- Which may contribute to otitis media? (Select all that apply.)
|a.||Exposure to cigarette smoke|
|c.||Upper respiratory infections|
|f.||Prolonged exposure to loud noise|
- What factors must the nurse consider when assessing readiness to learn when teaching health promotion practices for the visually and hearing impaired? (Select all that apply.)
- Which of the following are causes of cataracts? (Select all that apply.)
|a.||Long-term use of corticosteroids|
|c.||Congenital from exposure to maternal rubella|
|e.||Exposure to sand and dust|
- What would a nurse do when the patient arrives in the PACU after a left stapedectomy? (Select all that apply.)
|a.||Turn the patient to his right side|
|b.||Change dressing as it becomes soiled|
|c.||Turn patient every 2 hours|
|d.||Leave the bed flat|
|e.||Medicate immediately on the complaint of nausea|
- What should the nurse do when assisting a blind person to walk in an unfamiliar hospital environment? (Select all that apply.)
|a.||Discourage the use of the cane|
|b.||Advise the patient to walk quickly|
|c.||Describe the surroundings|
|d.||Encourage the patient to ask for verbal cues|
|e.||Place patient hand on nurse’s shoulder or elbow|
- The home health patient complains of tearing and a feeling of dryness in the right eye. The nurse assesses that the eyelid is turned inward and the sclera is red. The nurse documents the presence of a(n)_________________.
- The nurse explains that a pneumatic retinopexy is a repair of a retinal detachment using a bubble of_________ to put pressure on the damaged retina.
- The total removal of an eye is a(n) ___________.
- The surgical incision into the eardrum with either a knife or a heated wire loop to relieve pressure in the middle ear is a(n) ___________.
- Progressive deafness caused by the ankylosis of the stapes is the condition of__________.
- Arrange the parts of the eye from the exterior to the most interior. (Separate letters by a comma and space as follows: A, B, C, D)
- Aqueous humor
- Place the nursing intervention in appropriate order for the immediate care of a patient with a penetrating wound of the eye. (Separate letters by a comma and space as follows: A, B, C, D)
- Assess eye, do not remove object
- Cover both eyes with an eye shield or cup
- Lay the patient down flat
- Check for the irregularity of the pupil
- Obtain medical attention immediately
Chapter 14: Care of the Patient with a Neurologic Disorder
- What are the two divisions of the nervous system?
|a.||Somatic and the autonomic|
|b.||Cerebellum and the brainstem|
|c.||Medulla oblongata and the diencephalon|
|d.||Central and the peripheral|
- What is the cranial nerve that supplies most of the organs in the thoracic and abdominal cavities and also carries motor fibers to glands that produce digestive juices and other secretions?
|a.||Somatic motor nerve|
|b.||Visceral sensory nerve|
- The newly admitted patient to the emergency room 30 minutes ago after a fall off a ladder has gradually decreased in consciousness and has slowly reacting pupils, a widening pulse pressure, and verbal responses that are slow and unintelligible. What is the most appropriate position for the patient?
|a.||Neck placed in a neutral position|
|b.||Head raised slightly with hips flexed|
|c.||Supine in gravity neutral position|
|d.||Turn on right side with head elevated|
- Which question is likely to elicit the most valid response from the patient who is being interviewed about a neurologic problem?
|a.||“Do you have any sensations of pins and needles in your feet?”|
|b.||“Does the pain radiate from your back into your legs?”|
|c.||“Can you describe the sensations you are having?”|
|d.||“Do you ever have any nausea or dizziness?”|
- What is the cardinal sign of increased intracranial pressure in a brain injured patient?
|d.||Decrease in the level of consciousness|
- The nurse is aware that when assessing a patient by the FOUR score coma scale, the patient is assessed in four categories: eye response, brainstem reflexes, motor response, and respiration. How are these results reported?
|a.||As a sum of the scores of the four categories|
|b.||As part of the Glasgow coma scale|
|c.||As individual scores in each category|
|d.||As progressive scores during a 24-hour period|
- As the result of a stroke, a patient has difficulty discerning the position of his body without looking at it. In the nurse’s documentation, which would best describe the patient’s inability to assess spatial position of his body?
- A patient, age 45, is to have a myelogram to confirm the presence of a herniated intervertebral disk. Which nursing action should be planned with respect to this diagnostic test?
|a.||Obtain an allergy history before the test.|
|b.||Ambulate the patient when returned to the room after the test.|
|c.||Use heated blanket to keep patient warm after procedure.|
|d.||Keep NPO for 6 to 8 hours after the test.|
- A patient has recently suffered a stroke with left-sided weakness and has problems with choking, especially when drinking thin liquids. What nursing interventions would be most helpful in assisting this patient to swallow safely?
|a.||Use a straw|
|b.||Tuck chin when swallowing|
|c.||Take a sip of liquid with each bite|
|d.||Turn head to the left|
- What are surgical navigational systems?
|a.||Computerized devices that guide the surgeon|
|b.||A set of detailed anatomic maps pinpointing specific areas of the brain|
|c.||A written set of progressive processes for the resection of small brain tumors|
|d.||The use of radioactive materials to pinpoint small tumors of the brain|
- A family member of a patient who has just suffered a tonic-clonic seizure is concerned about the patient’s deep sleep. What is this behavior called?
|b.||Neural recovery period|
- How would a nurse record the behavior when a patient with Alzheimer disease attempts to eat using a napkin rather than a fork?
- Which symptom is specific to migraine headaches?
|b.||They become worse in the evening|
|c.||They involve the entire head|
|d.||They are preceded by an aura|
- The nurse assures an anxious family member of a 92-year-old patient who is demonstrating signs of dementia that many causes of dementia are reversible and preventable. What is one example?
- What is the nurse assessing when asking the patient, “Who is the president of the United States?” during a level of consciousness assessment?
|d.||Fund of knowledge|
- What Glasgow Coma Scale rating would a patient receive who opens the eyes spontaneously, but has incomprehensible speech and obeys commands for movement?
- What is the nurse aware of when assessing a person with a craniocerebral injury?
|a.||Most injuries of this type are irreversible|
|b.||Open injuries are always more serious than closed injuries|
|c.||Signs and symptoms may not occur until several days after the trauma|
|d.||Trauma to the frontal lobe is more significant than to any other area|
- The nurse is caring for a home health patient who had a spinal cord injury at C5 three years ago. The nurse bases the plan of care on the knowledge that the patient will be able to:
|a.||feed self with setup and adaptive equipment.|
|b.||transfer self to wheelchair.|
|c.||stand erect with full leg braces.|
|d.||sit with good balance.|
- A frantic family member is distressed about the flaccid paralysis of her son following a spinal cord injury several hours ago. What does the nurse know about this condition?
|a.||It is an ominous indicator of permanent paralysis.|
|b.||It is possibly a temporary condition and will clear.|
|c.||It degenerates into a spastic paralysis.|
|d.||It will progress up the cord to cause seizures.|
- A patient with a spinal cord injury at T1 complains of stuffiness of the nose and a headache. The nurse notes a flushing of the neck and “goose flesh.” What should be the primary nursing intervention based on these assessments?
|a.||Place patient in flat position and check temperature|
|b.||Administer oxygen and check oxygen saturation|
|c.||Place on side and check for leg swelling|
|d.||Sit upright and check blood pressure|
- The nurse is aware that the characteristic gait of the person with Parkinson disease is a propulsive gait, which causes the patient to:
|a.||stagger and need support of a walker.|
|b.||shuffle with arms flexed.|
|c.||fall over to one wide when walking.|
|d.||take small steps balanced on the toes.|
- What does the nurse know about the stroke patient who has expressive aphasia?
|a.||Has difficulty comprehending spoken and written communication|
|b.||Cannot make any vocal sounds|
|c.||Has total loss and comprehension of language|
|d.||Can understand the spoken word, but cannot speak|
- The nurse is aware that the drug t-PA (Activase), a tissue plasminogen activator, must be given in____hours of the onset of symptoms to have maximum benefit.
- An 83-year-old patient has had a stroke. He is right-handed and has a history of hypertension and “little” strokes. He presents with right hemiplegia. To afford him the best visual field, the nurse should approach him:
|a.||from the right side.|
|b.||from the left side.|
|c.||from the center.|
|d.||from either side.|
- The newly admitted patient to the emergency room after a motorcycle accident has serosanguineous drainage coming from the nose. What is the most appropriate nursing response to this assessment?
|a.||Cleanse nose with a soft cotton-tipped swab|
|b.||Gently suction the nasal cavity|
|c.||Gently wipe nose with absorbent gauze|
|d.||Ask patient to blow his nose|
- How would the nurse instruct a patient with Parkinson disease to improve activity level?
|a.||To use a soft mattress to relax the spine|
|b.||To walk with a shuffling gait to avoid tripping|
|c.||To walk with hands clasped behind back to help balance|
|d.||To sit in hard chair with arms for posture control|
- What is the basic problem that prompts most of the early signs of Alzheimer disease?
|a.||Changes in mood|
|c.||Memory loss that disrupts daily life|
|d.||Problems with words in speaking|
- A patient is in which stage of Alzheimer disease when she demonstrates “sundowning”?
- Why are the drugs neostigmine (Prostigmin) and pyridostigmine (Mestinon) helpful to the person with myasthenia gravis?
|b.||Improves visual disturbances|
|d.||Promotes nerve impulse transmission|
- What should the nurse do when the child arrives on the floor with the diagnosis of bacterial meningitis?
|a.||Arrange for humidified oxygen per mask|
|b.||Place the child in respiratory isolation|
|c.||Inquire about drug allergy|
|d.||Hold NPO until orders arrive|
- What is the purpose of a “drug holiday” in the treatment of Parkinson disease?
|a.||Change all drugs|
|b.||Allow the natural dopamine levels to rise|
|c.||Restart drugs at a lower dosage with favorable results|
|d.||Reduce the extrapyramidal symptoms|
- What is the first sign of Bell’s palsy?
|a.||Inability to wrinkle forehead and pucker lips on affected side|
|b.||Sudden pain in nostril on affected side|
|c.||Excessive salivation on the affected side|
|d.||Excessive mucus running from nostril on affected side|
- Following a myelogram the nurse should include in the postprocedure care assessment for:
|a.||elevation of blood pressure.|
|c.||sensation in lower extremities.|
- Why is the patient with suspected Guillain-Barre Syndrome (GBS) hospitalized immediately?
|a.||The infection needs to be treated with IV antibiotics to prevent paralysis|
|b.||The brain may swell quickly causing seizures|
|c.||The disease can rapidly progress into respiratory failure|
|d.||IV hydration is needed to prevent possible fatal hypotension|
- Which foods should the person who suffers from migraine headaches avoid? (Select all that apply.)
- What are the three signs of Cushing response? (Select all that apply.)
|a.||Increased pulse rate|
|b.||Increased blood pressure|
|c.||Widened pulse pressure|
|e.||Increased systolic blood pressure|
- Which of the following techniques are necessary for safely feeding a hemiplegic patient? (Select all that apply.)
|a.||Mixing liquids and solid foods together|
|b.||Taking the patient’s dentures out to prevent choking|
|c.||Checking the affected side of mouth for food accumulation|
|d.||Offering small bites of food|
|e.||Elevating the patient to no more than 30 degrees|
|f.||Adding a thickening agent to liquids|
- What is the reticular activating system (RAS) essential to? (Select all that apply.)
- What are the effects of normal aging on the nervous system? (Select all that apply.)
|a.||Small vessel occlusion|
|b.||Loss of neurons|
|c.||Calcification of cerebrum|
|d.||Reduction of cerebral blood flow|
|f.||Decrease in oxygen use|
- _________________ is/are responsible for the transmission of impulses between synapses.
- A ___________ is a diagnostic procedure used to identify lesions by observing the flow of radiopaque dye through the subarachnoid space.
- The nurse explains that the triad of signs of Parkinson disease is: _______, _______ and _______
- Involuntary rhythmic movement of the eyes, with oscillations that may be horizontal, vertical, or mixed movements, is called ___________________
- The waxy substance that covers the neuron fibers and increases the rate of transmission of impulses is the ________.
- The nurse explains that the two divisions of the autonomic nervous system work to maintain homeostasis. Place in order the autonomic events. (Separate letters by a comma and space as follows: A, B, C, D)
- Parasympathetic nervous system dominates
- Extremely stressful or frightening event
- Blood pressure, heart rate, and adrenaline output decrease
- Sympathetic nervous system dominates
- Heart rate and blood pressure rise, secretion of adrenaline
Chapter 15: Care of the Patient with an Immune Disorder
- Which of the following is an example of immunocompetence?
|a.||A child that is immune to measles because of an inoculation|
|b.||A person who has seasonal allergies every fall|
|c.||When the symptoms of a common cold disappear in 1 day|
|d.||A neonate having a natural immunity from maternal antibodies|
- An anxious patient enters the emergency room with angioedema of the lips and tongue, dyspnea, urticaria, and wheezing after having eaten a peanut butter sandwich. What should be the nurse’s first intervention?
|a.||Apply cool compresses to urticaria|
|b.||Provide oxygen per non-rebreathing mask|
|c.||Cover patient with a warm blanket|
|d.||Prepare for venipuncture for the delivery of IV medication|
- What is the etiology of autoimmune diseases based on?
|a.||Reaction to a “superantigen”|
|b.||Immune system producing no antibodies at all|
|c.||T cells destroying B cells|
|d.||B and T cells producing autoantibodies|
- A patient is admitted with a secondary immunodeficiency from chemotherapy. The nursing plan of care should include provisions for:
|d.||maintaining high fluid intake.|
- The nurse takes into consideration that when the antigen and antibody react, the complement system is activated which:
|a.||toughens the cell wall.|
|b.||generates more T cells.|
|d.||makes the antigen resistant.|
- How does normal aging change the immune system?
|a.||Depresses bone marrow|
|b.||T cells become hyperactive|
|c.||B cells show deficiencies in activity|
|d.||Increase in the size of the thymus|
- What would the nurse recommend for a 94-year-old home health patient with deteriorated cell-mediated immunity?
|a.||Avoiding the influenza vaccine|
|b.||Getting pneumonia vaccine|
|c.||Having skin tests for all antigens|
|d.||Taking large doses of beta-carotene|
- A patient who works in a plant nursery and has suffered an allergic reaction to a bee sting is stabilized and prepared for discharge from the clinic. During discussion of prevention and management of further allergic reactions, the nurse identifies a need for additional teaching based on which comment?
|a.||“I need to think about a change in my occupation.”|
|b.||“I will learn to administer epinephrine so that I will be prepared if I am stung again.”|
|c.||“I should wear a Medic-Alert bracelet indicating my allergy to insect stings.”|
|d.||“I will need to take maintenance doses of corticosteroids to prevent reactions to further stings.”|
- What is the substance released by the T cells that stimulates the lymphocytes to attack an inflammation?
- Immediately after the nurse administers an intradermal injection of a suspected antigen during allergy testing, the patient complains of itching at the site, weakness, and dizziness. Which action by the nurse is most appropriate initially?
|a.||Elevate the arm above the shoulder|
|b.||Administer subcutaneous epinephrine|
|c.||Apply a warm compress to area|
|d.||Apply a local anti-inflammatory cream to the site|
- Which person is most at risk for a hypersensitivity reaction?
|a.||26-year-old receiving his second desensitization injection|
|b.||35-year-old starting back on birth control tablets|
|c.||The 52-year-old started on a new series of Pyridium for cystitis|
|d.||The 84-year-old receiving penicillin for an annually recurring respiratory infection|
- The nurse recommends to the busy mother of three that the antihistamine fexofenadine (Allegra) would be more beneficial than diphenhydramine (Benadryl) because Allegra:
|b.||contains a stimulant for an energy boost.|
|c.||does not dry out the mucous membranes.|
|d.||does not induce drowsiness.|
- The patient who had an asthma-like reaction to a desensitization shot was medicated with a subcutaneous injection of epinephrine. What effect should the nurse assure the anxious patient this will have?
|c.||Cause productive coughing|
|d.||Reduction of pulse rate|
- Health care facilities have reduced the incidence of serious latex reactions by:
|a.||Having local and injectable corticosteroids on hand for employees|
|b.||Desensitizing staff who are allergic|
|c.||Supplying extra handwashing stations in the halls|
|d.||Using only powder-free gloves|
- What should the nurse include to assess for in the plan of care for a patient undergoing plasmapheresis?
- A patient is undergoing immunotherapy on a perennial basis. With this form of treatment, what should the patient receive?
|a.||Larger doses each week|
|b.||Higher concentrations each week|
|c.||Increased amounts and concentrations in 6-week cycles|
|d.||The same amount and concentration each visit|
- What is the term for transplantation of tissue between members of the same species?
- In which patient should the nurse be most concerned about immunodeficiency disorder?
|a.||The patient taking desensitization injections (immunotherapy)|
|b.||The patient on long-term radiation therapy for cancer|
|c.||The overweight patient|
|d.||The patient recently diagnosed with lupus erythematosus|
- What is the purpose of plasmapheresis in the treatment of rheumatoid arthritis?
|a.||To add corticosteroids to relieve pain|
|b.||To remove pathologic substances present in the plasma|
|c.||To remove waste products such as urea and albumin|
|d.||To add antinuclear antibodies|
- The nurse explains that when the patient received tetanus antitoxin with the antibodies in it, the patient received a ___________ type of immunity.
- Because the older adult has decreased production of saliva and gastric secretions, they are at risk for:
|b.||fissures in corners of the mouth.|
- What is the major negative effect of cell-mediated immunity?
|a.||Depression of bone marrow|
|b.||Rejection of transplanted tissue|
|c.||Activation of the T cells|
|d.||Stimulation of the B cells|
- What is B-cell proliferation dependent on?
|a.||Presence of NK (natural killer) cells|
- What timeframe must blood be transfused within once it has been removed from refrigeration?
- The LPN/LVN has arrived at the patient’s bedside with a unit of packed cells to be connected to an IV that is infusing. When the RN arrives, what is the first thing the nurses must do?
|a.||Check to ensure that the donor and recipient numbers match according to policy|
|b.||Request the patient to sign the card on the packed cells|
|c.||Immediately administer the packed cells|
|d.||Check the patient’s ID bracelet and then administer the packed cells|
- The nurse arrives at the bedside of a patient who has had a unit of packed cells infusing in his right arm for 35 minutes. He is complaining of chills, itching, and shortness of breath. What should be the nurse’s initial action?
|a.||Cover with a warm blanket|
|b.||Take the patient’s temperature|
|c.||Elevate the head of the bed|
|d.||Stop the transfusion and continue with saline|
- Which symptom would be classified as a mild transfusion reaction?
- What should the nurse do because of the increasing strength of the dose in the injections for immunotherapy?
|a.||Observe the patient for at least 20 minutes after administration|
|b.||Take the vital signs every 10 minutes for an hour|
|c.||Have the patient lie down quietly for an hour|
|d.||Place a warm compress on the area to speed its absorption|
- If a nurse is sensitive to latex gloves, what potential food sensitivities might the nurse develop? (Select all that apply.)
- Which of the following provide the body with innate immunity? (Select all that apply.)
|a.||Skin and mucous membranes|
|d.||Tears and saliva|
|e.||Natural intestinal and vaginal flora|
- Which of the following are diseases which result from one’s own immune system attacking the body? (Select all that apply.)
- The nurse outlines the functions of the immune system as those actions which: (Select all that apply.)
|a.||Prevention of hemorrhage|
|b.||Protection of the body’s internal environment|
|c.||Maintenance of hemoglobin level|
|d.||Maintenance of homeostasis by removing damaged cells|
|e.||Destruction of growth of abnormal cells|
- To provide examples of an active acquired immunity, the nurse uses the example of a person who has acquired immunity from measles because that person has had: (Select all that apply.)
|a.||Chickenpox and mumps|
|c.||An extremely healthy immune system|
|d.||An inoculation against measles|
|e.||Maternal antibodies against measles|
- What is humoral immunity based on? (Select all that apply.)
|a.||Production of antibodies by B cells|
|b.||T cells are activated by an antigen|
|c.||The body’s response to an antigen|
|d.||Sensitized T cells destroy the antigen|
|e.||Helper T cells activate phagocytosis|
- The nurse stresses that when a person produces his own antibodies against a specific antigen, that process of immunity is ______________ ________________ immunity
- A type IV latex allergy is characterized by________ _______.
- The process of immunity through a controlled exposure to an attenuated organism to stimulate the production of antibodies is _______________.
- A transfusion using blood from one’s own blood is a(n) ___________ transfusion, which is the best defense against a transfusion reaction.
- The transfer of tissue between genetically identical individual (twins) is a(n) ________.
- The nurse outlines for a patient who has asthma attacks from pollen that the process from exposure to symptoms follows a systematic sequence. Place the physiologic responses of an allergic asthma attack in sequence. (Separate letters by a comma and space as follows: A, B, C, D)
- Release of histamine
- Activation of mast cells
- Exposure to pollen
- List the sequence of a plasmapheresis procedure. (Separate letters by a comma and space as follows: A, B, C, D)
- Removal of whole blood in one arm
- Circulation of blood through cell separator
- Remainder of plasma returned through vein in opposite arm
- Separation of plasma and its cellular components
- Replacement of plasma with lactated Ringer
- Removal of undesirable components
Chapter 16: Care of the Patient with HIV/AIDS
- When assigned to a newly admitted patient with AIDS, the nurse says, “I’m pregnant. It is not safe for me or my baby if I am assigned to his case.” Which is the most appropriate response by the charge nurse?
|a.||“This patient would not be a risk for your baby if you use standard precautions and avoid direct contact with blood or body fluids.”|
|b.||“You should ask for a transfer to another unit because contact with this patient would put you and your baby at risk for AIDS.”|
|c.||“Wear a mask, gown, and gloves every time you go into his room and use disposable trays, plates, and utensils to serve his meals.”|
|d.||“We should recommend that this patient be transferred to an isolation unit.”|
- The anxious male patient is fearful that he has been exposed to a person with an HIV infection. He states he does not want to go to a laboratory for the ELISA tests because he does not want to be identified. What would be the nurse’s most helpful response?
|a.||“There really is not an option, you will need to get the Western blot test first.”|
|b.||“There is an FDA-approved home test called OraQuick.”|
|c.||“The rapid test Reveal can identify all the HIV strains.”|
|d.||“You can be tested anonymously for ELISA. If you are seronegative, your concerns are over.”|
- The patient, age 21, has been treated for chlamydia and has a history of recurrent herpes. What should the nurse counsel this patient about?
|a.||Sexual history, risk reduction measures, and testing for HIV|
|b.||Getting an appointment at a family planning clinic|
|c.||Testing for HIV and what the test results mean|
|d.||Abstinence and a monogamous relationship|
- A patient has just been diagnosed as HIV-positive. He asks the nurse, “Does this mean I have AIDS?” Which response would be most informative?
|a.||“Most people get AIDS within 3 to 12 weeks after they are infected with HIV.”|
|b.||“Don’t worry. You may never get AIDS if you eat properly, exercise, and get plenty of rest.”|
|c.||“It varies with every individual, but the average time is 8 to 10 years from the time a person is infected, and some go much longer.”|
|d.||“You can expect to develop signs and symptoms of AIDS within 6 months.”|
- Which of the following is a CDC criterion for the progression of HIV infection to AIDS?
|a.||Increase in viral load|
|b.||Decreased ratio of CD8 to CD4|
|c.||Increase in white blood cells|
|d.||Increased reactivity to skin tests|
- What should the nurse look for when reviewing a patient’s chart to determine whether she has progressed from HIV disease to AIDS?
|a.||CD4+ count below 500, chronic fatigue, night sweats|
|b.||HIV-positive test result, CD4+ count below 200, history of opportunistic disease|
|c.||Weight loss, persistent generalized lymphadenopathy, chronic diarrhea|
|d.||Fever, chills, CD4+ count below 200|
- A male patient is advised to receive HIV antibody testing because of his multiple sexual partners and injectable drug use. What should the nurse inform the patient to ensure understanding?
|a.||The blood is tested with the highly sensitive test called the Western blot.|
|b.||The blood is tested with an ELISA; if positive, it is tested again with an ELISA, followed by a Western blot if the second ELISA is positive.|
|c.||A series of HIV tests is performed to confirm if the patient has AIDS.|
|d.||If the HIV tests are seronegative, the patient can be assured that he is not infected.|
- A 28-year-old married attorney with one child is in the first trimester of her second pregnancy. The patient states that she is at no risk for HIV, so she would not need to be counseled about testing for HIV. Which is the most appropriate response?
|a.||“She’s a professional woman in a monogamous relationship. She obviously is not at risk.”|
|b.||“Women are not at great risk. The greatest risk is with gay men.”|
|c.||“The fastest-growing segment of the population with AIDS is women and children. We need to assess her risks.”|
|d.||“We need to review her chart to determine if her first child was infected.”|
- A young gay patient being treated for his third sexually transmitted disease does not see why he should use condoms, because “they don’t work.” Which is the most appropriate response?
|a.||“Condoms may not provide 100% protection, but when used correctly and consistently with every act of sexual intercourse they reduce your risk of getting infected with HIV or other sexually transmitted diseases.”|
|b.||“You are correct. Condoms don’t always work, so your best protection is to limit your number of partners.”|
|c.||“Condoms do not provide 100% protection, so you should always discuss with your sexual partners their HIV status or ask if they have any STD.”|
|d.||“Condoms do not provide 100% protection, but when used with a spermicide you can be assured of complete protection against HIV and other STDs.”|
- A 21-year-old male who has been an IV heroin user has been experiencing fever, weight loss, and diarrhea and has been diagnosed as having AIDS. At this time, he has a low-grade fever, severe diarrhea, and a productive cough. He is admitted with Pneumocystis jiroveci. What should the nurse do when caring for the patient?
|a.||Use a gown, mask, and gloves when assisting the patient with his bath|
|b.||Wear a gown when assisting the patient to use the bedpan|
|c.||Use a gown, mask, and gloves to administer oral medications|
|d.||Use a mask when taking the patient’s temperature|
- The nurse should instruct the patient who is diagnosed with AIDS to report signs of Kaposi sarcoma, which include:
|a.||Reddish-purple skin lesions|
|b.||Open, bleeding skin lesions|
- A patient states that he feels terrific, but a blood test shows that he is HIV-positive. It is important for the nurse to discuss with him that HIV may remain dormant for several years. What is true of the patient during this time?
|a.||He is not dangerous to anyone.|
|b.||He experiences minor symptoms only.|
|c.||He experiences decreased immunity.|
|d.||He is contagious.|
- To be diagnosed as having AIDS, the patient must be HIV-positive, have a compromised immune system without known immune system disease or recent organ transplant, and present with which of the following?
|b.||A positive ELISA or Western blot test|
|c.||Weight loss, fever, and generalized lymphedema|
|d.||CD4+ lymphocyte count less than 200 mm3|
- Why should interventions such as promotion of nutrition, exercise, and stress reduction be undertaken by the nurse for patients who have HIV infection?
|a.||They will promote a feeling of well-being in the patient.|
|b.||They will improve immune function.|
|c.||They will prevent transmission of the virus to others.|
|d.||They will increase the patient’s strength and ability to care for himself or herself.|
- A male patient is concerned about telling others he has HIV infection. What should the nurse stress when discussing his concerns?
|a.||Care providers and sexual partners should be told about his diagnosis.|
|b.||There is no reason to hide his disease.|
|c.||Secrecy is a poor idea because it will lower his self-esteem.|
|d.||His diagnosis will be obvious to most people with whom he will come into contact.|
- The HIV patient asks the nurse about what to expect in terms of disease progression. The nurse tells this patient that although the disease can vary greatly among individuals, the usual pattern of progression includes:
|a.||viremia, clinical latency, opportunistic diseases, and death.|
|b.||asymptomatic phase, clinical latency, ARC, and AIDS.|
|c.||acute retroviral syndrome, early infection, early symptomatic disease, and AIDS.|
|d.||transitional viral syndrome, inactive disease, early symptomatic infection, and opportunistic diseases.|
- While teaching community groups about AIDS, what should the nurse indicate as the most common method of transmission of the HIV virus?
|a.||Sexual contact with an HIV-infected partner|
|c.||Exposure to contaminated blood|
|d.||Nonsexual exposure to saliva and tears|
- What do the activated monocytes and macrophages produce in the presence of an inflammatory process?
|a.||Reduction of red cells|
|b.||Increase in WBCs|
|d.||Increase in T-helper cells increase natural killer (NK) cells|
- For most people who are HIV-positive, marker antibodies are usually present 10 to 12 weeks after exposure. What is the development of these antibodies called?
- What should the nurse emphasize when counseling an anxious HIV-positive mother about the care of her HIV-positive infant?
|a.||The baby will develop AIDS and refer her to a local AIDS support group. The baby will remain HIV-positive for the rest of its life.|
|b.||Although infants of HIV-infected mothers may test positive for HIV antibodies, not all infants are infected with the virus.|
|c.||She has not yet developed AIDS, and that it is possible the baby will not develop AIDS for many years.|
|d.||If the infant is started on zidovudine (AZT) within the first month after delivery, AIDS can be prevented.|
- Why are snacks high in potassium, such as bananas and apricot nectar, recommended?
|a.||Electrolytes are lost through diaphoresis.|
|b.||Sodium is lost through frequent diarrhea.|
|c.||Potassium will support weight gain.|
|d.||Potassium helps fight infection.|
- The depressed patient with AIDS says, “I don’t understand why I am going to be getting doses of testosterone. What good will that do me now?” What should the nurse keep in mind about testosterone when responding?
|a.||It can lower viral load|
|b.||It can lighten depression|
|c.||It can increase lean body mass|
|d.||It can increase appetite|
- After what period of time would the home health nurse make a mental health appointment for a patient with an HIV infection after assessing a diminished ability to attend to daily functioning?
- The HIV-infected patient who has just seroconverted says he just cannot take all those confusing, expensive antiretroviral (ART) medications. He says he still feels fine, anyway. What should the nurse keep in mind when counseling this patient?
|a.||Resumption of the ART later in the disease is just as effective|
|b.||Adherence to the ART protocol is essential to the success of the treatment|
|c.||Cessation of the ART may prevent the emergence of a resistant strain of HIV|
|d.||Once ART is initiated it cannot be restarted in the same patient|
- What medication times should the nurse use in writing out a schedule for taking antiretroviral medication three times a day?
|a.||8 AM – 2 PM – 8 PM|
|b.||8AM – 4PM – 12 AM|
|c.||8AM – 5PM – 1 AM|
|d.||Be given with meals|
- Which of the following are early signs and symptoms of an HIV infection? (Select all that apply.)
- Which of the following are methods in which children with AIDS could have contracted their disease? (Select all that apply.)
|a.||During intrauterine life with an HIV-positive mother|
|b.||During the birth process of an HIV-positive mother|
|c.||From other children who are HIV positive|
|d.||From receiving a transfusion contaminated with the HIV virus|
|e.||From breastfeeding by an HIV-positive mother|
- The home health nurse designing a teaching plan for a person with HIV disease that would support weight gain would include information pertaining to (Select all that apply.)
|a.||Limit fluid intake|
|b.||Eating high-protein/high-calorie diet|
|c.||Drinking nutritional supplements (Boost, Sustacal, etc.)|
|d.||Eating several small meals during the day|
|e.||Providing referrals to dietitians|
|f.||Resistance weight training|
- Which foods would a nurse recommend for a person with debilitating diarrhea as a result of HIV infection? (Select all that apply.)
|d.||Cooked fruits and vegetables|
- How does the HIV-2 virus compare to the HIV-1 virus? (Select all that apply.)
|a.||It has lower mortality risks in the older adult|
|b.||It is less virulent|
|c.||It is less infectious in the initial stage of infection|
|d.||It predisposes the HIV-infected person to a normal life span|
|e.||It develops high viral loads|
- Which of the following are examples of the AIDS wasting syndrome in a patient with an HIV infection? (Select all that apply.)
|a.||Episodes of vomiting for 20 days|
|b.||Appearance of Kaposi sarcoma|
|c.||Loss of 10% of body mass|
|d.||Marked hair loss|
|e.||Episodes of diarrhea for 30 days|
|f.||Episodes of hypotension|
- ______________ is a type of sexual option classified as “no risk” for a person to become infected with the HIV virus.
- An organism that can cross from an animal species to humans is a(n) ____________organism.
- The nurse explains that an enzyme ____________ ____________ allows the RNA of the retrovirus to be changed to DNA and incorporated into the host’s genetic material.
- The term that describes an immunosuppressed patient’s inability to react to a skin test is __________________.
- The combination of efforts of the medical team, nutritionist, social workers, and clergy is the necessary ______________ approach to the complex needs of the patients with HIV infection.
- The historical progress of the HIV infection began to be tracked in 1979. Arrange the historical events in sequence of their discovery. (Separate letters by a comma and space as follows: A, B, C, D)
- Infection in heterosexual men and women
- Infection in hemophiliacs
- Infection in injection drug users
- Increased incidence of Kaposi carcinoma in young homosexual men
- Increased incidence of Pneumocystis jiroveci (previously PCP)
Chapter 17: Care of the Patient with Cancer
- A patient has developed stomatitis from chemotherapy. What should the appropriate intervention for this condition include?
|a.||Instruction in the following of a liquid diet|
|b.||Using a commercial mouthwash after each meal|
|c.||Cleaning teeth with a cotton swab dipped in hydrogen peroxide|
|d.||Using a soft toothbrush|
- Which of the following men should be highest priority for referral for a prostate-specific antigen (PSA)?
|a.||43-year-old Hispanic man|
|b.||45-year-old African American man|
|c.||49-year-old Korean man|
|d.||50-year-old Native American man|
- A patient, age 56, has been advised that his prostate-specific antigen (PSA) level is elevated. The physician then performed a digital rectal examination (DRE). What should the next definitive diagnostic test be?
|c.||Needle biopsy of the prostate|
- How would the nurse explain to the patient who is taking cyclophosphamide (Cytoxan), an alkylating agent, about how the medication works?
|a.||It inhibits DNA and RNA synthesis|
|b.||It interferes with DNA replication|
|c.||It damages the cell in S phase of replication|
|d.||It alters the hormonal environment that promotes cancer growth|
- After an elevation of his PSA, the patient has blood drawn for a CA-19-9. When he asks the nurses the purpose of this new test, what is the most appropriate response?
|a.||It tests for hepatobiliary cancer|
|b.||It tests for colorectal cancer|
|c.||It tests for bladder cancer|
|d.||It tests for lung cancer|
- A patient, age 39, receiving chemotherapy for treatment of her cancer has a white blood cell count of 1600/mm3. This finding requires nursing interventions to provide which of the following?
|a.||Adequate fluid intake|
|b.||Protection from falls|
|c.||Protection against infection|
|d.||Frequent small nutritious snacks|
- What should the home health nurse advise the patient who found a lump in her breast a week ago during breast self-examination?
|a.||Arrange for an examination by her physician|
|b.||Wait until her next ovulatory cycle and check the lump again|
|c.||Postpone appointment until the lump enlarges|
|d.||Apply warm, moist compresses|
- How many minutes of daily exercise does the American Cancer Society recommend as a prevention of cancer?
- Using the TNM staging classification system, what does a tumor staged as T4N3M2 mean?
|a.||No evidence of primary tumor, lymph node involvement, or distant metastasis|
|b.||Carcinoma in situ, regional lymph node involvement, and metastasis to one site|
|c.||Enlarging tumor, increasing lymph node involvement, and distant metastasis|
|d.||Enlarging tumor, no lymph node involvement, or distant metastasis|
- A home health patient undergoing radiation therapy says, “I feel so useless. I have no energy, no appetite and I fall asleep whenever I sit down.” What is the nurse’s most therapeutic response?
|a.||“Fatigue is part of your illness. Taking several long naps in the daytime is helpful.”|
|b.||“Fatigue is an unfortunate side effect of radiation. It will improve when you finish treatment.”|
|c.||“You really shouldn’t be fatigued. Let me make an appointment with your physician to get this checked out.”|
|d.||“Don’t worry about it. You probably deserve the rest!”|
- The nurse instructs a patient who has been smoking for 5 years about the warning signs of cancer. The nurse tells him that one of cancer’s seven warning signals include:
|a.||nagging cough or hoarseness.|
|b.||a sore that does not heal rapidly.|
- Which of the following is a meal that would represent foods that help prevent cancer?
|a.||Broiled steak, baked potato, whole wheat roll, soy milk|
|b.||Baked ham, rice and gravy, apples stewed in butter, whole milk|
|c.||Fried pork chops, candied sweet potatoes, white rolls and butter, iced tea|
|d.||Broiled chicken, cabbage with onion and garlic, and soy milk|
- When should the nurse schedule the oral administration of metoclopramide (Reglan)?
|a.||Only at bedtime|
|c.||30 minutes before meals|
|d.||30 minutes after meals|
- What happens during the process of immunosurveillance?
|a.||T cells recognizing and destroying the abnormal cell|
|b.||White cells (WBC) destroying the abnormal cell|
|c.||Excretion of histamine to interfere with the replication of the abnormal cell|
|d.||B cells attaching to abnormal cell|
- The nurse caring for a patient who is being treated for cancer of the cervix by a radioactive implant discovers that the applicator with the radioactive material has become dislodged and is lying in the bed between the patient’s legs. What should the nurse do?
|a.||Using long-handled forceps grasp the applicator and wrap it in a towel|
|b.||Help the patient to a chair and cover the applicator with a rubber sheet|
|c.||Reassure the patient by staying at the bedside and call for help|
|d.||Notify the charge nurse|
- Which of the following people should avoid visiting a patient being treated with internal radiation therapy?
|a.||A 78-year-old using a walker|
|c.||A woman pregnant in the third trimester|
|d.||A 24-year-old nursing mother|
- A patient, age 63, has terminal cancer of the liver and is cared for by his wife at home. His abdominal pain has become increasingly severe, and he now says it is intense most of the time. The nurse recognizes that teaching regarding pain management has been effective based on which measure implemented by this patient?
|a.||Limiting the use of opiate analgesics to prevent addiction|
|b.||Using analgesics only when the pain becomes more than he can tolerate|
|c.||Taking analgesics around the clock on a regular schedule, using additional doses for breakthrough pain|
|d.||Resigning himself to the fact that pain is an inevitable consequence of cancer|
- A female patient, age 59, has lost 10 lb in the first 3 weeks of her chemotherapy and does not eat because nothing tastes good. What would be the appropriate nursing diagnosis for the plan of care?
|a.||Ineffective health maintenance, related to lack of knowledge of nutritional requirements during radiation therapy|
|b.||Risk for infection, related to poor nutrition|
|c.||Imbalanced nutrition: less than body requirements, related to anorexia|
|d.||Ineffective therapeutic regimen management, related to refusal to eat|
- What measures would the home health nurse, designing nursing interventions for a patient receiving external radiation treatments for a malignancy, recommend to protect the patient’s skin?
|a.||Applying warm compresses to damaged skin|
|b.||Encouraging patient to apply fragrant lotion to skin|
|c.||Patting the skin dry after the bath|
|d.||Exposing skin to sun for 10 minutes a day|
- Which statement is most appropriate for a nurse to tell a patient before insertion of the radioactive implant?
|a.||“Nurses will always be available, but they will spend only short periods of time at your bedside.”|
|b.||“Personal cleanliness is essential, so you will be given a complete bed bath each day.”|
|c.||“Your diet will be changed to a high-fiber diet to encourage daily bowel movements.”|
|d.||“Your bed linens will be completely changed each day to minimize radioactive contamination.”|
- A male patient is undergoing external radiation therapy on an outpatient basis for treatment of Hodgkin disease. After 2 weeks of treatment, he tells the nurse that he is so tired he can hardly get out of bed in the morning. Which is an appropriate goal?
|a.||Take two rest periods during the day|
|b.||Ambulate in the hall four times a day|
|c.||Select two activities for distraction|
|d.||Investigate a consultation with a psychiatrist for treatment of depression|
- The patient receiving radiation therapy complains of the conspicuous markings on the skin. What can the nurse explain about these markings?
|a.||They are residues of the treatment and can be washed off.|
|b.||They are caused by radiation and will fade in time.|
|c.||They are indicators of the amount of radiation the patient is receiving.|
|d.||They are gridlines for treatment and should be left on.|
- Nursing interventions for the nursing diagnosis of Imbalanced nutrition: less than body requirements would include all these except:
|a.||provide adequate, easily digestible, soft, bland foods.|
|b.||give small, frequent, highly nutritional meals.|
|c.||allow extra time to eat.|
|d.||offer three regular meals of highly nutritious foods.|
- A patient who has malignant cancer secondary to a high-grade lymphoma has been admitted with muscle weakness, tetany, paresthesia, and convulsion. The nurse notices the patient is being treated for tumor lysis syndrome (TLS) and initial treatment has not been successful. What should the nurse tell the family is the next step in treatment?
|a.||Whole blood transfusion|
|b.||A bone marrow biopsy|
|c.||Immediate radiation treatment|
- Which of the following are thrombocytopenic precautions?
|a.||Requesting an order for aspirin for discomfort|
|b.||Trimming toenails close|
|c.||Using an electric razor|
|d.||Vigorous tooth cleaning|
- The nurse explains to a 43-year-old patient with a benign tumor in her right breast that a benign tumor differs from a malignant tumor in that benign tumors:
|a.||do not cause damage to adjacent tissue.|
|b.||are simply an overgrowth of normal cells.|
|c.||do not spread to other tissues and organs.|
|d.||frequently recur in the same site.|
- Why is seeking medical attention when any cancer warning signs occur frequently delayed?
|a.||Difficulty accessing a physician or getting a referral consult.|
|b.||Lack of knowledge of the seven warning signs of cancer.|
|c.||Fear of the possible diagnosis of cancer and hoping signs will go away.|
|d.||Self-examination being complex and difficult to perform.|
- The nurse knows which of the following to be characteristics of malignant tumors?
|a.||Smooth, well defined; movable when palpated|
|b.||Resembles parent tissue; rarely fatal|
|c.||Rate of growth varies; rarely contained within a capsule|
|d.||Remains localized; slow growth|
- The difference between an excisional biopsy and an incisional biopsy is that an excisional biopsy involves the:
|a.||use of a needle to obtain fluid samples.|
|b.||removal of the entire lesion.|
|c.||taking a “bite” from the lesion for study.|
|d.||shaving of the superficial layers of the lesion.|
- What is the function of organizations like The Lost Chord Club, Reach for Recovery, and I Can Cope?
|a.||Arrange for transportation to a clinic|
|b.||Provide a small amount of financial support to patients|
|c.||Send volunteers to speak with a person facing a lifestyle change|
|d.||Arrange for reduced drug costs|
- Which of the following characteristics is common in malignant tumors?
|a.||Usually contained within a capsule|
|b.||Divide and multiply in the same manner as normal cells|
|c.||Proliferate and respond to treatment|
|d.||Progress and destroy surrounding tissues while spreading to distant parts of the body|
- Which of the following are nursing interventions for the nursing diagnosis of Imbalanced nutrition: less than body requirements? (Select all that apply.)
|a.||Provide adequate, easily digestible, soft, bland foods.|
|b.||Give small, frequent, highly nutritional meals.|
|c.||Allow extra time to eat.|
|d.||Offer three regular meals of highly nutritious foods.|
- Select the foods that are recommended for prevention of colorectal cancer in men. (Select all that apply.)
- The nurse is aware that American men and women have which of the following three sites for cancer in common? (Select all that apply.)
- Which of the following are risk factors for cancer? (Select all that apply.)
|f.||Exposure to ultraviolet light|
- What would the nurse encourage the patient to look for during self-testicular testing? (Select all that apply.)
|a.||Smooth consistency of testicle|
|d.||Heavy feeling in the scrotum|
|e.||Enlarged blood vessels in scrotum|
- What are the signs and symptoms of prostatic enlargement? (Select all that apply.)
|a.||Rotten egg odor to urine|
|d.||Difficulty starting urine flow|
|e.||Strong flow of urine|
- How do cancer cells differ from normal cells? (Select all that apply.)
|a.||They replicate in an organized manner.|
|b.||They have larger nuclei.|
|c.||They have an irregular shape.|
|d.||They have a different number of chromosomes.|
|e.||They have a different mitosis process.|
- The term ____________ refers to the process by which a normal cell is transformed into a cancer cell.
- Men over age 50 should consider an annual _________ test and rectal examination.
- The American Cancer Society recommends a clinical breast examination by a health care professional for women between the age of 20 and 39 years every ________ years.
- A ___________ test screens for occult blood in the stool.
- The nurse remarks that the American Cancer Society (ACS) reports that cancer is the ______ leading cause of death in the United States.