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Phipps’ Medical Surgical Nursing Health And Illness Perspectives, 8Th ed By Frances Monahan

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

Chapter 3: Healthy Lifestyles

MULTIPLE CHOICE

 

  1.    During a regular physical examination, a clinical nurse specialist counsels a patient on tobacco cessation. This type of preventive action is classified as:
1. Primary
2. Secondary
3. Tertiary
4. Screening

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Implementation  MSC: Client Needs: Health Promotion and Maintenance

 

  1.   Which of the following is a form of secondary prevention?
1. Tetanus booster
2. 10-pound weight loss
3. Mammography and Pap smear
4. Physical therapy for a neck strain

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Women’s health

TOP:  Nursing Process: Assessment        MSC: Client Needs: Health Promotion and Maintenance

 

  1.    Which meal selection coincides most closely with the Healthy People 2010 goals for nutrition?
1. Vegetable lasagna, lettuce salad, whole wheat roll, 2% milk
2. 6-oz pork chop, creamed peas, au gratin potatoes, coffee
3. BLT sandwich, french fries, 8-oz whole milk
4. Pasta alfredo, garlic bread, 8-oz cola

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1.   A patient’s 24-hour diet history includes four servings of bread, three servings of fruit, one serving of vegetables, three servings of beef or chicken, and one glass of whole milk. A nurse concludes that the diet is:
1. Low in complex carbohydrates, vegetables, and milk products
2. Meeting requirements of the Food Guide Pyramid
3. Adequate for all food groups except vegetables
4. Low in milk products, proteins, and fruits

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    A 56-year-old man with a 45-year history of smoking expresses a desire to quit smoking. An appropriate nursing diagnosis is:
1. Ineffective individual coping related to stress
2. Health-seeking behavior (desire to quit smoking)
3. Ineffective health maintenance related to inadequate support system
4. Impaired gas exchange related to decreased functional lung tissue

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Health Promotion and Maintenance

 

  1.    An appropriate weight reduction goal for any obese adult would be:
1. Reduce body fat to approximately 25%
2. Limit calories to 900 per day
3. Increase physical activity
4. Lose 5 pounds per week

 

 

ANS: 3                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1.   A 50-year-old woman is planning an exercise program. Her target heart rate for exercise should be:
1. 100 to 120 beats/min
2. 119 to 145 beats/min
3. 38 to 166 beats/min
4. 180 to180 beats/min

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Which exercise plan reflects basic health goals for cardiovascular fitness?
1. Low-impact aerobics for 60 minutes once a week
2. Brisk walking for 20 minutes four times a week
3. Bicycling for 30 minutes every weekend
4. Weight lifting once a week

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1.    When planning care for a middle-aged man with insomnia, it might be helpful to include:
1. Vigorous exercise before bedtime to promote fatigue
2. A relaxing activity before bedtime, such as reading
3. Afternoon naps to avoid extremes in fatigue
4. A hearty bedtime snack

 

 

ANS: 2                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1.   A 55-year-old man stops taking his antihypertensive medication because his blood pressure has been normal. To promote adherence to the therapeutic regimen, the nurse should:
1. Instruct his wife to administer the medication
2. Ask family members to remind and monitor him
3. Review the rationale for taking blood pressure medication with the patient
4. Contract with the patient to take the medication if his blood pressure becomes elevated again

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1.   Instruction on the safe use of nicotine gum should include teaching the patient that:
1. She or he should gradually reduce smoking while chewing the gum
2. She or he should chew the gum until “peppery” taste appears, then discard
3. Chewing too quickly can cause dizziness
4. Soreness of the mouth is expected

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

Chapter 13: Preoperative Nursing

 

MULTIPLE CHOICE

 

  1. Which nursing diagnosis is most appropriate for a patient during the preoperative phase of surgery?
1. Hypotension related to blood loss
2. Risk for pain related to the surgical incision
3. Anxiety related to fear of postoperative pain
4. Deficient knowledge regarding care of the surgical incision

 

 

ANS: 3                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Safe Effective Care Environment

 

  1. If a preoperative medication has been administered to a patient and the nurse notes that the operative consent form has not been properly signed and witnessed, the nurse will:
1. Have the patient sign a new consent form
2. Inform the surgeon of the situation immediately
3. Ask a family member to verify the patient’s signature
4. Obtain verbal permission from the patient to continue with the surgery

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Who is ultimately responsible for obtaining preoperative informed consent from patients? The:
1. Surgeon
2. Primary nurse
3. Perioperative nurse
4. Attending physician

 

 

ANS: 1                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. The patient should be queried about which specific allergies during the preoperative assessment?
1. Silicone, camphor, and narcotics
2. Synthetic fabrics and plastic
3. Bee stings and snake venom
4. Iodine, tape, and latex

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Which nursing action may help decrease the preoperative patient’s anxiety?
1. Encouraging her to sleep until she is taken to the surgery suite
2. Reassuring her that she will be fine and has no need to worry
3. Spending time with her and answering all of her questions
4. Teaching her how to avoid postoperative complications

 

 

ANS: 3                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Implementation  MSC: Client Needs: Psychosocial Integrity

 

  1. Which information about the patient must be communicated to the anesthesiologist or nurse anesthetist?
1. Family history of anesthetic complications
2. Urinary and bowel patterns
3. Sedentary lifestyle habits
4. Dietary preferences

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. The ability of a 71-year-old patient to tolerate surgery depends on the:
1. Number of past surgical procedures she has undergone
2. Degree of visual and auditory deterioration she is experiencing
3. Extent of physiological changes that have occurred due to aging
4. Type of preoperative medications and anesthetic that will be administered

 

 

ANS: 3                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1. Which question best elicits information regarding patients’ understanding of their scheduled surgery?
1. “Explain the reason for your admission to the hospital this morning.”
2. “Tell me about the surgical procedure you are having today.”
3. “Have you undergone this type of surgery in the past?”
4. “Do you understand why you are having surgery?”

 

 

ANS: 2                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Assessment        MSC: Client Needs: Health Promotion and Maintenance

 

  1. Which is an important outcome of preoperative preparation for any patient? The patient will:
1. Read all literature about the surgery before it is scheduled to take place
2. Be ready to leave the nursing unit for the surgical department on time
3. Ask questions regarding the surgery if he or she so desires
4. Report optimal rest in the hours before surgery

 

 

ANS: 3                    PTS:   1

DIF:   Category: Emotional needs related to health problems  TOP:  Nursing Process: Evaluation

MSC: Client Needs: Health Promotion and Maintenance

 

  1. The patient who is inactive or immobile is at increased risk for which surgical complication?
1. Atelectasis and probable pneumonia
2. Cardiac arrest during surgery
3. Postoperative incisional hernia
4. Urinary tract infection

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. When teaching the preoperative patient about diaphragmatic breathing, the nurse will tell the patient to:
1. “Exhale quickly through your nose and repeat six times in rapid succession.”
2. “Hold your breath for 10 seconds, then breathe out through your nose.”
3. “Inhale slowly through your nose and exhale through your mouth.”
4. “Lie flat so you can relax your abdomen and breathe fully.”

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Implementation  MSC: Client Needs: Health Promotion and Maintenance

 

  1. Which patient is at increased risk for developing postoperative thrombophlebitis?
1. A 45-year-old man having a hernia repair
2. A 70-year-old man having a radical prostatectomy
3. A 34-year-old woman having a modified radical mastectomy
4. A 55-year-old woman with diabetes having an abdominal hysterectomy

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1. Chronic use of which herb places the surgical patient at increased risk for bleeding?
1. Ginkgo
2. Ginseng
3. Echinacea
4. Kava kava

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1.   Which patient is least likely to experience pulmonary complications following surgery? It is the patient who:
1. Is hypertensive
2. Smokes cigarettes
3. Has a chest deformity
4. Weighs 20 pounds over ideal

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which factor contributes most to the development of acute renal failure in surgical patients?
1. Procedures lasting more than 2 hours
2. Interoperative hypotension
3. Electrolyte imbalances
4. Abdominal surgeries

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which is the goal of managing patients with diabetes mellitus during the perioperative period?
1. Stabilization of blood glucose level
2. Maintenance of fluid and electrolyte balance
3. Consistent monitoring of blood glucose level
4. Administration of insulin at 15-minute intervals

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Endocrine

TOP:  Nursing Process: Planning             MSC: Client Needs: Physiological Integrity

 

  1.   Which diagnostic study is generally omitted from preoperative screening?
1. Complete blood count with differential
2. 12-lead electrocardiogram
3. Coagulation studies
4. Chest radiography

 

 

ANS: 4                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

Chapter 23: Cancer

 

MULTIPLE CHOICE

 

  1. Which activity is a risk factor for colon cancer?
1. Consuming four to five servings of grains and cereals per day
2. Eating large amounts of fruits and vegetables
3. Eating a diet with 40% to 50% fat content
4. Selecting foods high in vitamins C and D

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which symptom represents a classic warning sign for cancer?
1. Fatigue
2. Low back pain
3. Burning on urination
4. Indigestion and dysphagia

 

 

ANS: 4                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Assessment        MSC: Client Needs: Health Promotion and Maintenance

 

  1. Which group should receive the focus of primary prevention based on rates of cancer incidence?
1. Elderly Hispanics
2. Native Americans
3. Young African Americans
4. Middle-aged European Americans

 

 

ANS: 3                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1. An anaplastic cell is best described as:
1. A cell that has increased in size
2. A well-differentiated malignancy
3. A cell that has undergone an irreversible change
4. An irregularly shaped cell that has atrophied

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. A malignancy identified as a carcinoma originates from:
1. Nerve fibers
2. Smooth muscle
3. Adipose tissue
4. Epithelial lining

 

 

ANS: 4                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Malignant neoplasms differ from benign tumors in that they:
1. Grow slowly
2. Are encapsulated
3. Infiltrate surrounding tissues
4. Closely resemble parent tissue

 

 

ANS: 3                    PTS:   1                    DIF:   Category: No applicable category

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. A grade III, stage III adenocarcinoma of the colon is a tumor that is:
1. Structurally similar to normal tissue
2. Slow growing and unlikely to spread
3. Confined to the colon
4. Invading other tissues

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. The pathology report classifies a tumor as T1, N0, M0. This means that the tumor is:
1. Benign
2. Metastatic
3. Invasive
4. Malignant

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Clinical signs of cachexia include:
1. Early satiety and weight loss
2. Intense feelings of hunger
3. Marked depression
4. Headache

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. A 60-year-old woman diagnosed with small cell carcinoma of the lung complains of SOB, chest pain, cough, and facial and neck swelling. The most likely cause is:
1. Disseminated intravascular coagulation
2. Superior vena cava syndrome
3. Cardiomyopathy
4. Septic shock

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Cardiovascular

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. To assess for tumor lysis syndrome postchemotherapy, the nurse should monitor:
1. Serum electrolytes
2. Platelet and WBC counts
3. Arterial blood gas values
4. Hemoglobin and hematocrit

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Fluid and electrolyte

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Of the following four individuals, who is at greatest risk of developing breast cancer?
1. 20-year-old woman pregnant with her first child
2. 48-year-old menopausal woman who underwent menarche at age 13
3. 50-year-old nulliparous woman still menstruating
4. 55-year-old woman with eight children who began childbearing at age 35

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Reproductive and genitourinary

TOP:  Nursing Process: Assessment        MSC: Client Needs: Health Promotion and Maintenance

 

  1. A 45-year-old man asks his primary physician if it is advisable to have a PSA blood level done, since his father and brother have prostate cancer. The nurse expects the physician to recommend:
1. Waiting until age 50
2. Having a prostatectomy
3. Digital rectal exams every 6 months
4. Yearly PSA level and prostate exam

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Reproductive and genitourinary

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1. The physician suspects lung cancer in a client with shortness of breath and hemoptysis. The only definitive method of diagnosing cancer in this case is:
1. Sputum cytology
2. Incisional biopsy
3. Bronchoscopy
4. Chest x-ray

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Respiratory

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. A tumor marker commonly present in lung cancer is:
1. Carcinoembryonic antigen
2. Chorionic gonadotropin
3. Bence Jones protein
4. Antidiuretic hormone

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. The physician orders G-CSF to be administered subcutaneously to a cancer patient. The nurse knows this drug has been effective if which blood test improves?
1. Neutrophil count
2. Red blood cells
3. Hemoglobin
4. Albumin

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. The nurse gives priority for obtaining a blood pressure in the patient receiving:
1. A colony-stimulating factor
2. Monoclonal antibodies
3. Erythropoietin
4. Interferon

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. A client asks the nurse why he is receiving multiple radiation treatments instead of just one. The nurse’s response is based on the fact that:
1. Reoxygenation of tumor cells between doses makes them more radiosensitive
2. Splitting the course of radiation allows time for the patient to relax
3. It is less expensive to deliver smaller radiation doses
4. The total radiation dose would be lethal if administered all at once

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Reproductive and genitourinary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. To reduce radiation exposure from a uterine implant, the nurse should:
1. Work from the head of the bed
2. Wear a film badge as protection
3. Implement most care from the doorway
4. Wear gloves at all times when in the room

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Reproductive and genitourinary

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. Which signs and symptoms are consistent with an acute, grade 3 radiation reaction of the skin?
1. Slight erythema, diminished sweating
2. Dry, scaly skin; moderate edema
3. Moist desquamation, pitting edema
4. Ulceration, hemorrhage

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Integumentary

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Patients receiving radiation therapy to the abdomen or pelvis should be instructed to:
1. Limit fluid intake
2. Eat high-residue foods
3. Use over-the-counter laxatives
4. Check urine and stool for blood

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. A patient complains of severe pain following a radiation treatment to the esophagus and exhibits agitation. He is requesting morphine sulfate every 2 hours. The nurse should be alert for indications of:
1. Increased white blood cell and platelet counts
2. Dysphagia and dehydration
3. Nausea and vomiting
4. Morphine addiction

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. To help alleviate the anxiety of a patient receiving external radiation, the nurse explains that:
1. The patient is radioactive following treatment
2. Visitors will not be allowed following therapy
3. Skin burns may occur but are only temporary
4. Treatments cause fatigue but are not painful

 

 

ANS: 4                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Implementation  MSC: Client Needs: Psychosocial Integrity

 

  1. The teaching plan for a patient receiving their first radiation treatment includes instructions to:
1. Shower and bathe as usual to keep the area clean
2. Keep skin moist, since radiation has a drying effect
3. Avoid heating pads and ice packs on the treated field
4. Get plenty of fresh air and sunlight to promote healing

 

 

ANS: 3                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. Chemotherapeutic agents classified as cell cycle nonspecific work by destroying:
1. Cancer cells in the reproductive phase
2. Tumor cells in the phase of division
3. Tumor cells throughout the cell cycle
4. DNA in the S phase

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Discharge teaching for patients who are immunosuppressed should include notifying the physician when:
1. Temperature rises 1 to 2 above normal
2. Gums bleed during oral care
3. Hair begins to fall out
4. Appetite diminishes

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. After receiving high-dose Cytoxan, the patient is instructed to:
1. Void frequently and report bloody urine
2. Limit fluid intake to 1000 ml over the next 24 hours
3. Report changes in breathing pattern
4. Avoid using hair color

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. A woman with leukemia received chemotherapy 2 weeks ago. Admission lab work reveals neutrophil count 500/mm3 Hbg 9.0 g/dl, Hct 27%, and platelets 48,000/mm3. Based on admission data, the patient should be advised to:
1. Increase hygiene measures, especially hand washing
2. Use a firm-bristled toothbrush for frequent oral care
3. Eat more fresh fruits and vegetables
4. Hold all food and fluids

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. A client tells the nurse that she is afraid of permanent hair loss. Which response would be most appropriate?
1. “You’ll fit right in with the teenage crowd.”
2. “Don’t worry, it will grow back as pretty as it is now.”
3. “It will be very difficult to face your friends and family.”
4. “There are ways to conceal hair loss, which in this case is only temporary.”

 

 

ANS: 4                    PTS:   1

DIF:   Category: Emotional needs related to health problems

TOP:  Nursing Process: Implementation  MSC: Client Needs: Psychosocial Integrity

 

  1. Nursing care for the patient with stomatitis of the mouth and esophagus includes:
1. Limiting oral fluids
2. Normal saline rinses every 2 hours
3. Lemon glycerin swabs every 2 hours
4. Gargling with commercial mouthwash after meals

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1. Compared to an external venous access device, an implanted catheter:
1. Cannot be used for blood sampling
2. Requires daily heparin flushes
3. Costs less for care maintenance
4. Causes less discomfort

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Blood and immunity

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

 

Chapter 43: Intestinal Problems

 

MULTIPLE CHOICE

 

  1.    Excessive use of laxatives as treatment for chronic constipation can cause:
1. Hypercalcemia
2. Hyponatremia
3. Hyperkalemia
4. Hypokalemia

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1.    Which is the safest yet most effective treatment for chronic constipation?
1. High-fiber diet
2. Over-the-counter cathartics
3. Limiting fluids other than at mealtime
4. Increasing intake of cheese and milk products

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Health Promotion and Maintenance

 

  1.    Older adults with severe acute diarrhea must be closely monitored for which complication?
1. Dehydration
2. Hypernatremia
3. Metabolic alkalosis
4. Bicarbonate excess

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1.    Which are the most appropriate foods and fluids for a person with diarrhea?
1. Milk, gelatin, and clear carbonated beverages
2. Bananas, cranberry juice, and electrolyte-replacement drinks (e.g., Gatorade)
3. Orange juice, cola drinks, and applesauce
4. Clear liquids, low-fiber foods, and electrolyte solution

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1.    Which clinical manifestation is associated with acute appendicitis?
1. Fever greater than 102º F orally, severe thirst, and abdominal distention
2. Fever greater than 100º F orally and right lower quadrant rebound tenderness
3. Fever greater than 100º F rectally, diarrhea, abdominal distention, and tenderness
4. Fever greater than 101º F rectally, generalized abdominal tenderness, and rapid heart rate

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Which laboratory finding supports the presence of appendicitis?
1. Neutrophil count 50%
2. White blood cell count 100,000 mm3
3. White blood cell count 14,000 mm3
4. White blood cell count 5000 mm3

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Nursing actions for the patient with suspected appendicitis include:
1. Administering a cleansing enema in preparation for appendectomy
2. Ambulating the patient at least every 2 hours to decrease pain
3. Placing a heating pad over the abdomen to enhance comfort
4. Withholding pain medication until a diagnosis is established

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which organism is commonly identified as a cause of peritonitis?
1. Haemophilus influenzae
2. Candida albicans
3. Escherichia coli
4. Klebsiella

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. The nurse will prevent and/or detect which complication when caring for the patient with peritonitis?
1. Sepsis and septic shock
2. Fluid volume overload
3. Portal hypertension
4. Fissure formation

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which laboratory finding is commonly associated with the diagnosis of peritonitis?
1. Hematocrit 42%
2. White blood cell count 20,000/mm3
3. Potassium 100 mEq/L
4. Lymphocyte count below 4000/mm3

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which nursing action addresses the problems experienced by patients with peritonitis?
1. Encouraging a mechanically soft diet and 2000 ml of fluid per day
2. Maintaining complete bed rest with the head of the bed flat
3. Performing warm-saline peritoneal lavage every 2 hours
4. Administering total parenteral nutrition as ordered

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Diverticulitis is said to exist when:
1. The appendix ruptures, releasing bacteria and toxins into the diverticulum
2. Fecal material or bacteria become trapped in mucosal outpouchings
3. Peritoneal lavage irritates the mucosal lining of the diverticula
4. Perforation of the mucosal outpouchings of the intestine occur

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Diverticulitis commonly produces which clinical manifestation(s)?
1. Lower left quadrant cramping and low-grade fever
2. Vomiting coupled with chills and high fever
3. Fever and backache from referred pain
4. Severe, sharp abdominal pain

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. When teaching the patient with diverticulosis about prevention of the condition, it is appropriate to suggest:
1. Low-fiber foods such as popcorn or raw apples
2. High-fiber diet and bulk-forming laxatives
3. Mild laxatives and high-residue diet
4. Analgesics and low-fiber diet

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which group of individuals is at greater risk for developing inflammatory bowel disease?
1. American Jews
2. White women
3. Native Americans
4. African-American men

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1. Addressing which problem takes priority when caring for patients experiencing ulcerative colitis?
1. Pain
2. Nausea
3. Diarrhea
4. Flatulence

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1. Which is a feature of Crohn’s disease?
1. Involves the mucosal layer of the intestine only
2. May occur anywhere along the gastrointestinal tract
3. Primarily affects the right ileum
4. May often lead to toxic megacolon

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Stools that contain mucus, pus, and blood are often noted in patients with which condition?
1. Ulcerative colitis
2. Crohn’s disease
3. Celiac disease
4. Diverticulitis

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which medication is often of benefit to patients with inflammatory bowel disease?
1. Acetaminophen
2. Morphine
3. Docusate
4. Psyllium

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1. Which condition often occurs in patients with inflammatory bowel disease?
1. Visual disturbances
2. Topical allergies
3. Skin lesions
4. Arthritis

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which is a common side effect of the drug olsalazine, which is used to treat inflammatory bowel disease?
1. Fever
2. Diarrhea
3. Skin rash
4. Constipation

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. Patients with inflammatory bowel disease are often treated with steroids in combination with what other drugs?
1. Diuretics
2. Laxatives
3. Antibiotics
4. Antihypertensives

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Patients with irritable bowel syndrome are taught to avoid:
1. Rich, fatty foods
2. Bulk-forming laxatives
3. Motility agents such as cisapride
4. Bland, high gas-producing foods

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. An ileoanal anastomosis is a surgical procedure that involves:
1. Inserting and anastomosing the small intestine into a rectal stump, which is left after the colon is removed
2. A two-stage procedure in which a pouch from the terminal ileum is anastomosed above the anal sphincter
3. Removing a section of the colon above the rectum and anastomosing the ends together
4. Removal of the colon, rectum, and anus with permanent closure of the anus

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. The patient behavior “identifies factors that increase disease-related anxiety” best supports the expected patient outcome of:
1. Knowledge obtainment
2. Health maintenance
3. Grieving
4. Coping

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Psychosocial Integrity

 

  1. A primary goal of postoperative care for the patient undergoing a colostomy is achieving adequate:
1. Self-care
2. Skin care
3. Fluid replacement
4. Nutritional support

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. Which assessment finding of a stoma during the postoperative period is cause for concern?
1. Appears red and has blood around it
2. Is moist in appearance
3. Has a purplish color
4. Lacks sensation

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. An effective pouching system for a colostomy is one that:
1. Protects the skin, contains stool and odor, and molds to the body’s contours
2. Can be easily applied, reused, and emptied without removing it
3. Contains stool, has few if any leaks, and can be readily removed for emptying
4. Seals immediately, contains stool and odor, and can be reused numerous times

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1. Which of the following is considered a “mechanical” obstruction?
1. Megacolon
2. Paralytic ileus
3. Intussusception
4. Vascular infarction

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Most commonly, obstructions occur in the:
1. Small intestine
2. Large intestine
3. Ascending colon
4. Descending colon

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. Which is a sign of early bowel obstruction?
1. Polyuria
2. Absent bowel sounds
3. Sharp, unrelenting pain
4. Vomitus with fecal odor

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which is an important nursing activity for the patient with a bowel obstruction?
1. Careful monitoring of fluid and electrolyte status
2. Administering antibiotics for infection
3. Assisting the patient with ambulation
4. Monitoring food and fluid intake

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1. Which are known risk factors for developing colorectal cancer?
1. Diet and history of inflammatory bowel disease
2. Genetic predisposition and environment
3. History of excessive laxative use
4. Trauma and family history

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which is currently the most accurate method for early detection of colorectal cancer?
1. Colonoscopy
2. Serum carcinoembryonic antigen levels
3. Digital rectal examination
4. Stool occult blood screening

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Tumors in the right ascending colon are likely to produce which symptom?
1. Rectal bleeding
2. Pencil-shaped stool
3. Occult blood in the stool
4. Constipation alternating with diarrhea

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which problem is associated with prolonged paralytic ileus after colon surgery?
1. Obstructed gastrointestinal tube
2. Small-bowel infarction
3. Abscess or obstruction
4. Excessive narcotic analgesia

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Physiological Integrity

 

  1. On day 2 after colon surgery during which an ostomy was constructed, the patient is expected to:
1. Assist with own activities of daily living
2. Change own colostomy bag
3. Select foods that are not gas producing
4. Perform self-care of the ostomy site and bag

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Gastrointestinal

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

Monahan: Phipps’ Medical-Surgical Nursing: Health and Illness

Perspectives, 8th Edition

 

Test Bank

 

Chapter 53: Degenerative Disorders

 

MULTIPLE CHOICE

 

  1.    Which is true of gout?
1. It results in chronic inflammation of lower extremity joints
2. It occurs from urate crystal formation within the synovial tissues
3. It is associated with bursal sac inflammation and calcium deposits
4. It produces inflammation of muscle fibers, resulting in tissue necrosis

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    Patients with septic arthritis are taught to:
1. Recognize signs of recurring infection
2. Exercise the affected joint to prevent deformity
3. Soak the joint twice daily in a warm salt solution
4. Self-administer intravenous antibiotics and narcotics

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.    The diagnosis of Lyme disease is problematic because infection:
1. Remains dormant for many years before producing disease
2. Does not produce symptoms until years after the initial infection
3. Does not produce lymphadenopathy or systemic signs of infection
4. Often mimics other diseases, such as influenza or rheumatoid arthritis

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Analysis/Nursing Diagnosis

MSC: Client Needs: Physiological Integrity

 

  1.    Early disseminated infection with Borrelia burgdorferi is associated with:
1. Fatigue, headache, and lethargy
2. Heart failure, dyspnea, and fibromyalgia
3. Meningitis, dysrhythmias, and pericarditis
4. Memory loss, behavioral changes, and ataxia

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

 

  1.    Which is the typical spinal deformity produced by ankylosing spondylitis?
1. Lateral curve
2. Lordotic curve
3. Kyphotic curve
4. Rigid with no curve

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Patients with spondylitis are taught to:
1. Use a soft mattress
2. Sleep in a side-lying position only
3. Avoid the use of heat for pain control
4. Maintain proper posture and walk erect

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.    Which laboratory finding is expected for the patient with systemic lupus erythematosus?
1. Significantly decreased white blood cell count
2. Depressed erythrosedimentation rate
3. Positive antinuclear antibody assay
4. Negative LE prep

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.    Patients with systemic lupus erythematosus are taught:
1. Appropriate use of narcotic analgesics
2. Methods to reduce exposure to direct sunlight
3. Follow-up care, including yearly chest x-ray examination
4. The need for participating in an aggressive exercise program

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.    Collaborative care management for the person with polymyositis includes:
1. Long-term antibiotic therapy
2. 24-hour urine studies to determine cortisol levels
3. Electroencephalograms to determine seizure potential
4. A muscle biopsy to determine pathologic muscle changes

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

 

  1.   Where is pain of fibromyalgia syndrome typically located?
1. Eleven of the 18 tender point sites when palpated
2. Cervical neck, occiput, trapezius, and gluteal areas
3. Joints of the fingers and wrists without provocation
4. Along dermatome surfaces of the spinal lumbar region

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   Which is a characteristic of osteitis deformans (Paget’s disease)?
1. Decreased skin elastin
2. Nerve pain from bone deterioration
3. Loss of functional ability of the synovial joints
4. Excess bone destruction and unorganized repair

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   Which statement indicates that the patient with Paget’s disease has a good understanding of self-care?
1. “I will avoid extended periods of immobility.”
2. “I will participate in a weight-bearing exercise program.”
3. “I will take antacids to supplement my intake of magnesium.”
4. “I will eliminate high-calcium foods from my diet.”

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Evaluation          MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which is a goal of drug therapy for osteoporosis?
1. Decrease risk of fractures
2. Rebuild weakened bones
3. Increase bone resorption
4. Stimulate osteogenesis

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Drug-related responses

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which is an important, yet simple, measure to prevent osteoporosis?
1. Avoiding alcohol intake
2. Taking one aspirin every day
3. Performing weight resistance exercises
4. Bicycling for at least 3 miles every day

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

 

  1.   Teaching for the patient with chronic osteomyelitis includes information about:
1. Replacement of the affected joint
2. Use of long-term corticosteroids
3. Vitamin supplement schedules
4. Home antibiotic therapy

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which is a positive indicator of lower back pain?
1. Limited forward flexion
2. Limited hyperextension
3. Localized pain in the thoracic spine
4. Loss of sensation along lower extremities

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   Which is most beneficial to people with lower back pain?
1. Lumbar or pelvic traction
2. Stretching and flexion exercises
3. Complete bed rest for 1 to 2 weeks
4. Lumbar back-strengthening exercises

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Physiological Integrity

 

  1.   Surgical intervention is indicated for spinal disorders when the:
1. Injury involves the cervical spine
2. Condition lasts longer than a few weeks
3. Disorder produces a neurologic deficit
4. Patient disagrees with conservative treatment methods

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which is reported immediately if noted when assessing the surgical site and dressing after spinal surgery?
1. Slight redness and swelling of the surgical site
2. Serosanguineous drainage on the dressing
3. Tenderness around the surgical site
4. Clear fluid drainage on the dressing

 

 

ANS: 4                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which problem may be present when the patient’s hemoglobin and hematocrit levels are decreased 4 days after spinal surgery but vital signs are normal?
1. Syndrome of inappropriate release of antidiuretic hormone
2. Infection
3. Hemorrhage
4. Cerebrospinal fluid leakage

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   Which is the purpose of logrolling the patient after back surgery?
1. To help minimize pain and anxiety
2. To maintain correct spinal alignment
3. To prevent inflammation by stabilizing the spine
4. To allow the nurse to move the patient without assistance

 

 

ANS: 2                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Planning             MSC: Client Needs: Safe Effective Care Environment

 

  1.   Which is a risk factor for hallux valgus and bunion formation? Wearing shoes:
1. With pointed toes
2. That are too large
3. With heels more than one-half-inch high
4. Without socks for prolonged periods

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1.   Which group is at greatest risk for bone tumors? Persons:
1. With calcium deficiencies
2. Who are older and debilitated
3. Younger than 20 years and older than 60 years
4. Suffering repeated bone trauma

 

 

ANS: 3                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Assessment        MSC: Client Needs: Physiological Integrity

 

  1. Which nursing intervention is appropriate for the person undergoing limb salvage surgery?
1. Promotion of independence within capabilities
2. Teaching about the need for lifetime antibiotic therapy
3. Referral to clergy for discussions about the death process
4. Counseling to facilitate adjustment to living with a disability

 

 

ANS: 1                    PTS:   1                    DIF:   Category: Skeletal

TOP:  Nursing Process: Implementation  MSC: Client Needs: Safe Effective Care Environment